(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
20170SB0595PN0912 - 4 -
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