AFFIDAVIT OF OWNERSHIP CHANGE

I/We_______________________________________________, being the holder(s) of

Certificate of Purchase No.(s)___________,__________,__________,__________,
hereby request that the following name(s) be changed on the above listed
Certificate(s) of Purchase:

From: To:

This request in made for the following reason(s):

This request is made this_______day of _________________, _______, by the undersigned.

___________________________

___________________________

I/We the undersigned hereby state that I/We have full knowledge of this request
for the change of the name or name(s) as stated above.

Type: ____ Type: ______________________

Signed: ____ Signed: ____________________

SUBSCRIBED TO AND SWORN to before me this ______ day of _________________,

By:

_________________________
NOTARY PUBLIC

My Commission Expires:

SUBSCRIBED TO AND SWORN to before me this ______ day of _________________,

By:
_________________________
NOTARY PUBLIC

My Commission Expires:

BT106 (05/95)