(date)................................................
by (name(s) of individual(s)).........................
......................................................
as (type of authority, such as officer or trustee)
......................................................
who represent that (he, she or they) are authorized to
act on behalf of (name of party on behalf of whom record
was executed).........................................
......................................................
Signature of notarial officer.........................
Stamp
......................................................
Title of office.......................................
My commission expires:................................
(2.1) For an acknowledgment by an attorney at law
pursuant to 42 Pa.C.S. § 327 (relating to oaths and
acknowledgments):......................................
State of...............................................
County of..............................................
This record was acknowledged before me on
(date).................................................
by (name of attorney)..................................
Supreme Court identification number....................
as a member of the bar of the Pennsylvania Supreme Court
certified that he/she was personally present when
(name(s) of individual(s)) executed the record and that
(name(s) of individual(s)) executed the record for the
purposes contained therein.
Signature of notarial officer..........................
Stamp
A01569 - 4 -
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