STATE OF ________________)
ss:
COUNTY OF _______________)

KNOW ALL YE MEN BY THESE PRESENTS,

That on this _____ day of __________________, 20_____, personally came and appeared before me ___________________, of ____________________________, known, and known to me, who after being first duly sworn, deposes and says:

(Insert Sworn Statement)

FURTHER AFFIANT SAYETH NOT.

_________________________

SUBSCRIBED TO AND SWORN TO before me this ______ day of____________________, 20______.

___________________________
NOTARY PUBLIC

My Commission Expires _________

NOTICE

The information in this document is designed to provide an outline that you can follow when formulating business or personal plans. Due to the variances of many local, city, county and state laws, we recommend that you seek professional legal counseling before entering into any contract or agreement.