AFFIDAVIT

STATE OF _________________

COUNTY OF _________________

BEFORE ME, the undersigned authority, _________________[name and capacity of officer before whom affidavit is sworn], on this _________________[day of month] day of _________________[month], 20_________________, personally appeared _________________[name of affiant], known to me to be a credible person and of lawful age, who being by me first duly sworn, on _________________[his or her] oath, deposes and says: _________________[set forth statement of facts].

_________________[Signature of affiant]

_________________[Typed name of affiant]

_________________[Address of affiant]

Subscribed and sworn to before me, this _________________[day of month] day of _________________[month], 20 _________________.

[Seal]     _________________[signature of officer]     

        _________________[Typed name of officer]     

        _________________[Title of officer]     

        My commission expires: ____, 20____    

ACKNOWLEDGMENT

STATE OF _________________

COUNTY OF _________________

This instrument was acknowledged before me on _________________, 20_________________, by _________________[name(s) of person(s) acknowledging].

[Seal]     _________________[signature of officer]     

        _________________[Typed name of officer]     

        _________________[Title of officer]     

        My commission expires: ____, 20____