Specifications

Page 11 of 14
Page 4 of 4 ST-220-TD (6/06)
Individual, Corporation, Partnership, or LLC Acknowledgment
STATE OF }
: SS.:
COUNTY OF }
On the ______ day of _____________ in the year 20___, before me personally appeared
known to me to be the person who executed the foregoing instrument, who, being duly sworn by me did depose and
say that
_he resides at ,
Town of ,
County of ,
State of ; and further that:
[Mark an X in the appropriate box and complete the accompanying statement.]
(If an individual): _he executed the foregoing instrument in his/her name and on his/her own behalf.
(If a corporation): _he is
the of
, the corporation described in said instrument; that, by authority of the Board of Directors of said
corporation, _he is authorized to execute the foregoing instrument on behalf of the corporation for purposes set
forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on
behalf of said corporation as the act and deed of said corporation.
(If a partnership): _he is
a of
, the partnership described in said instrument; that, by the terms of said partnership, _he is authorized to
execute the foregoing instrument on behalf of the partnership for purposes set forth therein; and that, pursuant to
that authority, _he executed the foregoing instrument in the name of and on behalf of said partnership as the act
and deed of said partnership.
(If a limited liability company): _he is a duly authorized member
of LLC, the limited liability company described in said instrument;
that _he is authorized to execute the foregoing instrument on behalf of the limited liability company for purposes
set forth therein; and that, pursuant to that authority, _he executed the foregoing instrument in the name of and on
behalf of said limited liability company as the act and deed of said limited liability company.
Notary Public
Registration No.