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PROVIDER'S ACKNOWLEDGMENT <br /> <br /> State of ) <br /> SS. <br /> County of <br /> On this day of ,before me personally <br /> appeared , to me personally known, who being by me <br /> duly sworn, did say that he/she is the of <br /> .the PROVI R named in the foregoing instrument, and that <br /> he/she is authorized to sign said instrument n behalf of the PROVIDER, as provided in <br /> Recital E of the foregoing Agreement, and acknowledges that he/she executed said <br /> instrument as the free act and deed of the PRO DER. <br /> Notary Public, <br /> My commission a 'res: <br /> EXEMPT TRANSACTIONS <br /> Page 6 Form AG3-Exem(4/99) <br /> <br />