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(signature) <br /> (date) <br /> STATE OF <br /> COUNTY OF <br /> PERSONALLY APPEARED BEFORE ME, the undersigned authority, <br /> (name of individual signing) who, after first being <br /> sworn by me, affixed his/her signature in the space provided above on this day of <br /> 2003 . <br /> NOTARY PUBLIC <br /> My commission expires : <br /> STATEMENT OF PUBLIC ENTITY CRIMES <br /> S-3 <br />