Choose a building block.

Further affiant sayeth not.

Dated this	day of	,	20

as	of
(Signature)	(Type of Authority)	(Name of Entity)

State of
County of

This instrument was acknowledged before me on
(date)

by
(name of person(s))

as
(type of authority, e.g., president, trustee, member, partner, etc.)

of
(name of entity on behalf of whom instrument was executed)

(Seal)
Notary Signature Line
Notary Printed Name
Notary Public for State of
Residing at:
My Commission Expires:	/	/	20