State of
County of

I, enter text, being first duly sworn upon oath, deposes and says:

That enter text and enter text are one and the same person.

Further affiant sayeth not.

Dated this	day of	,	20

(Signature)

This instrument was acknowledged before me on
(date)

By

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