JURAT

SUBSCRIBED and sworn to before me, this ____ day of

_________________, in the City of _______________ by
_______________________ with Passport No.________________,
issued on __________________ at ____________________.

Doc. No. _______; NOTARY PUBLIC for ________

Page No. _______; Commission Serial No ________
Book No. _______; Until December 31, ________
Series of _______. Roll of Attorney ________
IBP No.____/Date/Place of Issue
PTR No.___/ Date/Place of Issue