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ss.:

I, .........., Consul-...... of the United States of America, .........., duly commissioned, and qualified, do certify that on this......day of 192.., before me personally appeared in said.............., to me known, and known to me to be the individual described in, whose name is subscribed to, and who executed the foregoing instrument, and being by me informed of the contents of said instrument ...... duly acknowledged to me that ...... executed the same freely, and voluntarily for the uses, and purposes therein mentioned.

IN WITNESS WHEREOF, I have hereunto set my hand and Official Seal the day, and year last above written.

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Consul-........ of the

United States of America at