AFFIDAVIT

WITNESS OF SIGNATURE BY MARK

_________________________________________________ (affiant's name), being unable to write, made ________________ (his or her) ______________ (X) mark

in my presence and I wrote _________________________________ (his or her) name

at ___________ (his or her) request.

_____________________________________ ____________________

Signature of Witness writing Affiant’s Name Dated

_____________________________________ ____________________

Signature of Other Witness Dated