BLANK PROOF OF EXECUTION BY SUBSCRIBING WITNESS FORM

State of California
County of _______________} ss.

On _______________ (date), before me, the undersigned, a notary public for the state, personally appeared _______________ (subscribing witness's name), proved to me to be the person whose name is subscribed to the within instrument, as a witness thereto, on the oath of _______________ (credible witness's name), a credible witness who is known to me and provided a satisfactory identifying document. _____________________(subscribing witness's name) being by me duly sworn, deposed and said that he/she was present and saw/heard ________________ (name(s) of principal(s)), the same person(s) described in and whose name(s) is/are subscribed to the within, or attached, instrument in his/her/their authorized capacity(ies) as (a) party(ies) thereto, execute or acknowledge executing the same, and that said affiant subscribed his/her name to the within instrument as a witness at the request of _______________ (name(s) of principal(s)).

WITNESS my hand and official seal.

Notary Public Signature                                                         Notary Public Seal


SAMPLE COMPLETED PROOF OF EXECUTION BY SUBSCRIBING WITNESS FORM

State of California
County of Los Angeles} ss.

On January 1, 2008, before me, the undersigned, a notary public for the state, personally appeared James Madison, proved to me to be the person whose name is subscribed to the within instrument, as a witness thereto, on the oath of George Washington, a credible witness who is known to me and provided a satisfactory identifying document. James Madison being by me duly sworn, deposed and said that he/she was present and saw/heard Thomas Jefferson, the same person(s) described in and whose name(s) is/are subscribed to the within, or attached, instrument in his/her/their authorized capacity(ies) as (a) party(ies) thereto, execute or acknowledge executing the same, and that said affiant subscribed his/her name to the within instrument as a witness at the request of Thomas Jefferson.

WITNESS my hand and official seal.

Bob D. Notary