JURAT

SUBSCRIBED and sworn to before me, this ___ day of ___________, in the City of
____________________ by ____________________ with Passport No. ___________ issued on
____________________ at ____________________.

Doc. No. __________; NOTARY PUBLIC for __________

Page No. __________; Commission Serial No. _________
Book No. __________; Until December 31, ____________
Series of __________. Roll of Attorney _______________
IBP No. ____/Date/Place of Issue
PTR No. ____/Date/Place of Issue