INTERVIEWEE or FACT WITNESS

    STATE OF _______________)
    COUNTY OF _____________)

    Personally or legally appeared before me, the undersigned authority in and for the aforesaid County and aforesaid State, Affiant, who acknowledged that he signed, executed, and delivered the above and foregoing answers on the date thereof and that same are true and correct to the best of his/her knowledge and belief. Given under my hand and official seal the date above.

    ____________________________
    NOTARY PUBLIC
    My commission expires: