WPCN j x}XHpe:BcƾkW(PXIS^И"2V 2a {^V|f"%,zm:7.E{J߬9Br'O(/q&< .x &I4ΧÙB {y]K%[6Lvk J  Onthe__dayof_____intheyear____beforeme,theundersigned,personallyappeared  h _________,thesubscribingwitnesstotheforegoinginstrument,withwhomIampersonally  U  acquainted,who,beingbymedulysworn,diddeposeandsaythathe/sheresidesin  B  ___________(iftheplaceofresidenceisinacity,includethestreetandstreetnumber,ifany, /  thereof);thathe/sheknows________tobetheindividualdescribedinandwhoexecutedthe   foregoinginstrument;thatsaidsubscribingwitnesswaspresentandsawsaid_______execute   thesame;thatsaidwitnessatthesametimesubscribedhis/hernameasawitnessthereto;and   thatsaidsubscribingwitnessmadesuchappearancebeforetheundersignedin______________.   (Insertthecityorotherpoliticalsubdivisionandthestateorcountryorotherplaceinwhichthe  proofwastaken.) m _____________________________ 4 (Signatureandofficeofindividual !q takingproof.) ^