STATE OF ________________
ss:
COUNTY OF _______________
KNOW ALL YE MEN BY THESE PRESENTS,
That on this ______ day of __________________, 20_____, personally came and appeared before me ___________________, of ____________________________, known, and known to me, who after being first duly sworn, deposes and says:
(Insert Sworn Statement)
SUBSCRIBED TO AND SWORN TO before me this ______ day
of____________________, 20______.
___________________________
NOTARY PUBLIC
My Commission Expires ________ , 20___