IN WITNESS WHEREOF, I have hereunto affixed my signature this 16th

day of ______, 2019 at ______ City.

ABC
Affiant

SUBSCRIBED and sworn to before me, this ____th day of

_________ 2019, in _______ City. I hereby certify that I personally
examined the affiant; that she has voluntarily, knowingly and intelligently
executed the foregoing and that she fully understands it contents.

ADMINISTERING OFFICER

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