In witness whereof, the undersigned have hereunto set their hand this ____ day of ________ A.D., 19__.

________, ________, ________
________, ________, ________

On this ____ day of ________, 19__, before me, A.B., a justice of the peace, in and for the said county, personally appeared the above named ________, ________, ________, ________, who are personally known to me to be the identical persons whose names are affixed to the above articles, as parties thereto, and they severally acknowledged the instrument to be their voluntary act and deed.

Witness my hand the date aforesaid.

A.B.
Justice of the Peace.


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