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3 <br />(Organization Owner) <br />___________________________________ <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 Angela M. Smith. <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.