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:
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[set forth affiant's statement of facts]
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[signature of affiant]
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[typed name of affiant]
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[address of affiant, line 1]
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[address of affiant, line 2]
Subscribed and sworn to before me, this _________________ [day of month] day of _________________ [month], 20 ____ .
[Notary Seal:]
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[signature of Notary]
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[typed name of Notary]
My commission expires: ________________ , 20 ____ .