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Acknowledgment by Committee or Conservator for Incompetent
STATE OF ----------)
COUNTY OF ---------)
On this [date] before me personally came [name], to me known as the
individual described in and who executed the foregoing instrument and
known to me to be the Committee [or, Conservator] of [name], an
incompetent (Conservatee). The individual by said Committee [or,
Conservator] executed the foregoing instrument and acknowledged to me
that he executed the same as the act and deed of the incompetent
(Conservatee) pursuant to the order of the [court, county] therein
Witness my hand and official seal.
My commission expires: _____