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1.0.1 certify that, to the best of my knowledge and belief and under penalty of perjury, the <br />information herein is true, correct and eotnpletc. <br />Executed this ^ day of 2020 <br />Printed Name: <br />STATE OF <br />COUNTY OF <br />The foregoing affidavit was sworn to and subscribed before me on this _ day of <br />2020, by _ , proved to me on the basis of <br />satisfactory evidence to be the person who appeared before me. <br />(Notary Seal) <br />Notary Signature <br />16 <br />