JURAT

Subscribed and sworn to before me, this ____ day of

_______________, 20__, in the City [Municipality] of
__________________, by __________________ with Residence
Certificate no. ___________, issued at ______________,
____________, on ____, ___________, 20__.

NOTARY PUBLIC

PTR No. __________

IBP No. ______
Roll No. ______
Until ____, ___________, 20__

Doc. No. ____

Page No. ____
Book No. ____
Series of ____