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Affidavit State of West Virginia

State of West Virginia
County of ________________

BEFORE ME, the undersigned Notary, _____________ [name of Notary before whom affidavit is sworn], on this ____________ [day of month] day of _________ [month], 20__, personally appeared ________________________ [name of affiant], known to me to be a credible person and of lawful age, who being by me first duly sworn, on ________ [his or her] oath, deposes and says:

[set forth affiant's statement of facts]

__________________________
[signature of affiant]

__________________________
[typed name of affiant]

__________________________
[address of affiant, line 1]

__________________________
[address of affiant, line 2]

This Section for Notary:

ACKNOWLEDGMENT

State of _________

County of ________ [COUNTY]

On [DATE] before me, [NAME OF NOTARY], notary, personally appeared [NAME OF PERSON(S) INVOLVED], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

Signature ________
Notary

My commission expires: _____

(Seal)