State of Washington                                             County of San Juan













  Signed and sworn to (or affirmed) before me on __________/___________/_________
                                                    YYYY   /   Month   /   Day
       ⌜                              ⌝

                                            by __________________________________.

       

                                               __________________________________
                                                           (Signature)


                                               __________________________________
                                                              Title


       ⌞                              ⌟




                         My appointment expires __________________________________





















Text from Section 42.44.100 RCW                    © 2010 Collier Technologies LLC