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SIGNED SEALED AND DELIVERED )

by the abovenamed Donor ) Donor’s


NAME OF THE DONOR ) signature

in the presence of: )


___________________________
NAME OF THE DONOR

Stamp AND Signature of Consular


Officer or Notary Public

On this __ day of ________ before me, (name of the consular officer or


Notary Public), a (Consular Officer or Notary Public) officiating at (Address)
personally appeared NAME OF THE DONOR who of my own personal
knowledge I know to be the identical person whose name “NAME OF THE
DONOR” is subscribed to the within written instrument and acknowledged that
he/she had voluntarily executed this instrument in (country).

Witness my Hand.

Stamp AND Signature of Consular


Officer or Notary Public

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