AFFIDAVIT OF IMPUNITY

State of _______________________

Country of _____________________

I,________________(name), of _______________(adress), ________________(city), in _________(country), DO HEREBY SWEAR

UNDER OATH AND SAY THAT:

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Under penalty of prejury, I hereby declare and affirm that the above
stated facts, to the best of my knowledge, are true and correct.

Subscribed and sworn to before me, on the _______________________, ________________________________

day of ________________________, _________________ . (Signature)

________________________________________
(Signature of notary public)