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State of California State of California County of _______________ County of _______________ Subscribed and sworn to (or affirmed) before me on this _____ day of ____________, 20__, by________________________, Subscribed and the basis of affirmed) before me on be _____ proved to me on sworn to (or satisfactory evidence tothis the day of ____________, 20___, by________________________ person(s) who appeared before me. __________________________________________________, (Seal) Signature_______________________ proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.

(Seal)

Signature_______________________

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