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STATE OF MINNESOTA <br />COUNTY OF HENNEPIN <br />On this __ day of ______ , 20_, ______________ _ <br />personally appeared before me, <br />__ who is personally known to me <br />__ whose identity I proved on the basis of ________ _ <br />__ whose identity I proved on the oath/affirmation ________ , a credible <br />witness <br />and who executed the foregoing instrument, and acknowledged that he/she/they executed the <br />same as his/her/their free act and deed. <br />Notary Public <br />Page 5 of 5