)ss.:
County of ____________________)
On the ______ day of __________ in the year _____, before me, the
undersigned notary public, personally appeared _______________________,
personally known to me or proved to me on the basis of satisfactory
evidence to be the individual(s) whose name(s) is (are) subscribed to
the within instrument and acknowledged to me that he/she/they executed
the same in his/her/their capacity(ies), and that by his/her/their
signature(s) on the instrument, the individual(s), or the person upon
behalf of which the individual(s) acted, executed the instrument.
_________________________
Notary Public
Part II. Qualified Third Party Statement
I, (insert name of qualified third party), state as follows:
My employer name/address/phone number/e-mail address are as follows:
I am:
____ A law enforcement officer employed by the (insert law enforcement