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EXECUTED UNDER THE PAINS AND PENALTIES OF PERJURY ON THE DATE WRITTEN BELOW <br /> AFFIANT NO. 2 2 WITNESSES <br /> Signature: Signature: <br /> Print Name: Print Name: <br /> Date: <br /> Title: (circle one) Member, Partner, Director,Shareholder, Officer,Trustee <br /> Percentage Ownership or Voting Interest: % Signature: <br /> Print Name: <br /> WITNESS AND ACKNOWLEDGEMENT <br /> State/Commonwealth of <br /> County of <br /> On this day of , 201 , before me, <br /> the undersigned Notary Public, personally appeared , <br /> who proved to me on the basis of satisfactory evidence)to be the person(s)whose name(s) is/are subscribed <br /> to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their <br /> authorized capacity(ies), and that by his/her/their signature(s) on the instrument,the person(s) or the entity <br /> upon which the person(s) acted, executed the instrument. <br /> WITNESS my hand and official seal. <br /> Notary Public <br /> Print Name: <br /> My commission expires: [SEAL] <br /> Site No:370764 <br /> Site Name:Vero Beach Ring, FL <br />