JURAT

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

__________, this ____day of ___________, 20_____ by ________ with residence
Certificate Number ___________ issued at ______________ on ___________,
20____.

NOTARY PUBLIC
My Commission Expires
Dec. 31, 20__

Not. Reg. No. ______;

Page ____; Book ____;
Series of 20_________;