Notary Attestation Form

NOTARY ATTESTATION FORM

This Notary Attestation Form is executed by Signer Name: of Address: (the "Signer") and Notary Name: a Notary Public commissioned in the State of , County of (the "Notary").

RECITALS

WHEREAS, the Signer desires to have an attestation, acknowledgment or jurat performed with respect to the document described as: (the "Document");

WHEREAS, the Notary is duly commissioned and authorized under the laws of the State of to administer oaths, take acknowledgments and attest to signatures; and

WHEREAS, the Signer has requested the Notary to perform notarial acts in connection with the execution of the Document and to provide a formal attestation or certificate as required by law.

NOW, THEREFORE, in consideration of the mutual covenants contained herein, the parties agree as follows:

1. NOTARIAL ATTACHMENT AND CERTIFICATION

On this day of , , before me, the undersigned Notary, personally appeared the person whose name is signed to the Document and who is identified in this form as Signer. The Notary hereby attests that the Signer executed the Document and that the Notary has performed the notarial act selected below.

Type of notarial act (select one): Acknowledgment Jurat (oath or affirmation) Other

Identification of Signer: The Signer was identified to my satisfaction by:

Means of identification (check all that apply): State Driver's License Passport Personal Knowledge Credible Witness Other

Identification details (if applicable): Document Number or Description:

2. REPRESENTATIONS AND WARRANTIES

The Signer represents and warrants that the Signer is the individual whose name appears on the Document, that the Signer executed the Document freely, knowingly and voluntarily, and that the execution of the Document was not induced by fraud or duress. The Notary represents and warrants that the Notary is duly commissioned, has complied with applicable rules of procedure for notarial acts, and has no interest in the transaction evidenced by the Document.

3. NOTARY CERTIFICATION

I certify under penalty of perjury under the laws of the State of that the foregoing is true and correct and that the Notary made the required inquiry, identification, and performed the notarial act in accordance with applicable law.

Notary commission number: . Commission expiration: .

4. FEES

Notary fees charged for the performance of the notarial act, if any, are disclosed as follows: Amount paid or to be paid: $. Payment shall be made at the time of service unless otherwise agreed in writing.

5. NOTICES

6. AMENDMENTS; WAIVER; COUNTERPARTS

Any amendment to this Notary Attestation Form must be in writing and executed by both the Signer and the Notary. No waiver of any provision hereof shall be effective unless made in writing and signed by the waiving party. This form may be executed in counterparts, each of which shall be deemed an original and all of which when taken together shall constitute one instrument.

7. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This Notary Attestation Form shall be governed by and construed in accordance with the laws of the State of . This form constitutes the entire agreement between the Signer and the Notary with respect to the notarial services described herein and supersedes all prior agreements and understandings. If any provision of this form is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

8. INDEMNITY

The Signer agrees to indemnify and hold harmless the Notary against any claims, liabilities, losses, or expenses (including reasonable attorneys' fees) arising out of any false statements made by the Signer to induce the Notary to perform the notarial act, except to the extent caused by the Notary's gross negligence or willful misconduct.

9. EXECUTION

The parties have executed this Notary Attestation Form to be effective as of the date of the Notary's signature below.

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