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r . <br /> . , <br /> �7�"l�l� 1�17�n �� �- S7Crrar.0 _ <br /> Name of Ba�ik <br /> I3y: �j <br /> Addres:;: �L�vi��,���I�� lJ,�/LC �L/Y' i v�JO <br /> 7'ille:� � � 1 �J ���� <br /> -D���//N <br /> Telepl�one No.: _� ���j L� (�O �j_1 <br /> Con�act 1'erson. <br /> 1. I'or au acicno��icd�;emcnl iu :in indi��idual capncit}�: <br /> S"fATG OP �'✓ASI]ING7'ON. <br /> )ss <br /> COUNTY Oi� SN01101�4IS11 <br /> 1 ccrtif}' that I kno�c or ha�'c �atisfactor}' c�'idcncc thnt_ _ <br /> siened ihis ins4ument and acknowlcdged it to bc Qiis, her, lheir) ti'ce and �oluntary act for thc <br /> ttses and purp�,ses mcutioncd in Um instn:n:ent. <br /> I)alc.L• <br /> Sisnuiure of Notcuy Piiblic <br /> Notary (print name)_ <br /> Residing aC _ <br /> nt}� commissions expires: __ _ <br /> (Scal er Stnmp) <br /> A,sigiwicttt oE Funds, I'agc 2 of 3 <br />