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AFFIDAVIT

North Carolina

County of _______________

, appearing before the undersigned


Name of principal

notary and being duly sworn, says that:

1.

2.

Affiant

Sworn to (or affirmed) and subscribed before me this the _____ day of _____________,

20___.

(Official Seal)
Official Signature of Notary

, Notary Public
Notary’s printed or typed name

My commission expires:

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