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EXECUTED UNDER THE PAINS AND PENALTIES OF PERJURY ON THE DATE WRITTEN BELOW <br />AFFIANT NO.5 <br />Signature:_ <br />Print Name: <br />Date: <br />2 WITNESSES <br />Signature: _ <br />Print Name: <br />Title: (circle one) Member, Partner, Director, Shareholder, Officer, Trustee <br />Percentage Ownership or Voting Interest: <br />State/Commonwealth of <br />County of <br />Signature:_ <br />Print Name: <br />WITNESS AND ACKNOWLEDGEMENT <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: <br />[SEAL] <br />Site No: 370764 <br />Site Name: Vero Beach Ring, FL <br />