STATE OF NEW YORK County of...............

ss.:

On this ...... day of........ before me came .......... the subscribing witness to the foregoing instrument, with whom I am personally acquainted, who, being by me duly sworn, did depose and say, that he resided, at the time of the execution of said instrument, and still resides in ..........; that he is and then was acquainted with..........and knew......to be the individual described in, and who executed the foregoing instrument; and that he, said subscribing witness, was present and saw him execute the same; and that he, said witness, at the same time subscribed his name as witness thereto.

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Notary Public, ............County, No.......