SUBSCRIBED AND SWORN TO BEFORE ME on the date and place so
set forth above by the judicial affiant exhibiting his ___________________. I
FURTHER CERTIFY that (the judicial affiant personally signed before me the
foregoing and that he acknowledged) I have personally examined the affiant
and that I am satisfied that she had voluntarily executed and had fully
understood the (document).
Copy furnished
[ ] by personal service:
[ ] by registered mail due to considerable distance
lack of office personnel
Reg. Receipt No. _________________