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Example of Acknowledgement Signature of Witness Printed Name and Address of Witness Signature of Witness Printed Name and Address of Witness State of ______________________________ County of_____________________________ The foregoing instrument was acknowledged before me this ______________ day of __________________, 20____, by in the presence of these witnesses. (SEAL/STAMP) Notary Signature Print, Type or Stamp Name of Notary My commission expires___________________ John Doe , who signed by way of mark John X His Mark Doe

Example of Jurat Signature of Witness Printed Name and Address of Witness Signature of Witness Printed Name and Address of Witness State of _______________________________ County of______________________________ John X His Mark Doe

Sworn to (or affirmed) and subscribed before me this _____day of ______________, 20______, by of these witnesses. (SEAL/STAMP) Notary Signature Print, Type or Stamp Name of Notary My commission expires __________________ John Doe , who signed by way of mark in the presence

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Microsoft Word - EXAMPLE.doc
W:\Forms - Adoption\Engrossed forms\12.981(a)(3) - revised0304.wpd
Microsoft Word - EXAMPLE.doc