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(Organization Owner) <br /> By <br /> Printed <br /> Title <br /> (Organization Acknowledgment) <br /> 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 Jordan Wyatt, Area Plan Commission. <br /> I affirm under the penalties for perjury,that I have taken reasonable care to redact each Social <br /> Security number in this document, unless required by law. Jordan Wyatt. <br />