GENERAL AFFIDAVIT

Commonwealth of Pennsylvania
County of ________________


BEFORE ME, the undersigned Notary, ___________________________________________________  [name of Notary before whom affidavit is sworn], on this _________________  [day of month] day of _________________  [month], 20____, personally appeared ___________________________________________________  [name of affiant], known to me to be a credible person and of lawful age, who being by me first duly sworn, on ________  [his or her] oath, deposes and says:

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[set forth affiant's statement of facts]


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[signature of affiant]


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[typed name of affiant]


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[address of affiant, line 1]

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[address of affiant, line 2]


Commonwealth of Pennsylvania
County of ________________


On this, the _____ day of _________________, 20____, before me ________________________________________, the undersigned officer, personally appeared
_____________________________________________________________________________, known to me (or satisfactorily proven) to be the person(s) whose name(s) is/are subscribed to the within instrument, and acknowledged that __________________________________ executed the same for the purposes therein contained.

In witness whereof, I hereunto set my hand and official seals.


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Title of Officer