State of Washington                                             County of San Juan









I certify that the event or act described in this document has occurred or been
performed.


                                    Dated:    __________/___________/_________
                                                 YYYY   /   Month   /   Day
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                                          ________________________________________
                                                        (Signature)


                                          ________________________________________
                                                           Title


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                         My appointment expires __________________________________
















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