) ss
)
COUNTY of _____________ )
On the ____ day of _______________, 20___, before me, the undersigned, a Notary Public in and for said State, personally appeared
______________________
Personally known to me or proved to me on the basis of satisfactory
[ evidence] identification to be the individual whose name is subscribed to
the within instrument and acknowledged to me that he/she executed the same in his/her capacity, and that by his/her signature on the instrument,
the individual, or the person upon behalf of which the individual acted,
executed the instrument.
WITNESS my hand and official seal.
_________________________
Notary Public
Print Name: [Notary Public]
Notary Public State of New York
No. ______________
Qualified in _________County
Certificate Expires: _____________