THE JURAT

SUBSCRIBED and sworn to before me, in the city/municipality of __________________, this

___________ day of _________________, 20___________ by ___________________ with Residence Certificate
No. ________________ issued at ___________________ on ______________, 20_____.

NOTARY PUBLIC
My commission expires Dec. 31, 20__
Not. Reg. No._____________________;
Page No.________________________ ;
Book ___________________________;
Series of 20___________