Form No.

4-- JURAT

          SUBSCRIBED AND SWORN to before me, this....  day of  ...........  19....,
by........... who exhibited to me his Res. Cert. No. A-.......... issued at ..........on

                                                  Notary Public

                                                  Until December 31, 19. .
                                                  PTR No. .............

Doc. No. ........;

Page No. ..,....;
Book No. .......;
Series of 19.......

 *This is a certification by an officer authorized to administer oath, that the truth of the
statement was affirmed before him by the affiant.