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Acknowledgment by Attorney-in-Fact
STATE OF ----------)
COUNTY OF ---------)
On this [date] before me came [name], to me known and known to me to
be the individual who executed the foregoing instrument and who is
described in and appointed attorney-in-fact by a power of attorney
executed by [name] and dated [date], and she acknowledged that she
executed the foregoing instrument as the act of [name] and as his
Witness my hand and official seal.
My commission expires: _____