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JURAT

SUBSCRIBED AND SWORN to before me this _______ day of __________________, at


________________________________________. Affiant/s personally appeared and presented his/her/their
competent proof/s of identity as indicated below his/her/their name/s and signature/s, and known to me to be the
same person/s who personally signed before me the foregoing instrument/document and acknowledged that
he/she/they executed the same.

WITNESS MY HAND AND SEAL.

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