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FORM NO.

5 THE JURAT

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


this ____day of ________________, 19____ by ____________________________ with
Residence Certificate No. ____________________________ issued at __________________ on
________________, 19____.

NOTARY PUBLIC
My commission expires Dec. 31, 19____

Not. Reg. No. _______________;


Page ________; Book ________;
Series of 19____.

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