State of _______________________________________

County of _____________________________________

BEFORE ME, the undersigned authority, on this day personally appeared _______________________________ who being first duly sworn, deposes and says that:

An agreement for the Purchase and Sale of the real property
and further described in the attached Exhibit "At' was entered into by and between the Affiant, as Buyer, and as Seller, on the ______ day of ______________________________, 20______.

A copy of the agreement for purchase and sale of said real property may be obtained by contacting ___________________________________________________________________________________ whose mailing address is __________________________________________________________________________, and whose telephone number is ________________________________________________.

Dated this ______ day of ______________________________, 20______.

FURTHER AFFIANT SAYETH NOT.

Signed, sealed and delivered in the presence of:

Sworn to and described before me this ______ day of ______________________________, 20______.

(Seat)

NOTARY PUBLIC

STATE OF ______________________________

My commission expires ____________________

This instrument was prepared by:

____________________________________