State of:
County of:
On (date), before me, (print notary’s name here), personally appeared (print researcher’s name here) and:
[__] Is personally known to me.
OR
[__] Has proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to this form.
Witness my hand and official seal
Notary’s Signature
Print Notary Name
Notary Seal
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