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STATE OF <br />SS: <br />COUNTY OF <br />Before me, a Notary Public in and for said County and State, personally appeared <br />, the of <br />, a(n) , Owner(s) of <br />the real estate described above who acknowledged the execution of the foregoing instrument in <br />such capacity and who, having been duly sworn, stated that any representations therein contained <br />are true. <br />Witness my hand and Notarial Seal this day of , <br />Signature <br />Printed <br />County of Residence <br />My Commission expires: <br />This instrument was prepared by <br />F ) <br />E�i�? 0 r7 <br />