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PROVIDER'S ACKNOWLEDGMENT <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 PROV ER named in the foregoing instrument, and that <br /> he/she is authorized to sign said instrume ton behalf of the PROVIDER, as provided in <br /> Recital E of the foregoing Agreement, a d acknowledges that he/she executed said <br /> instrument as the free act and deed of the PRO IDER. <br /> Notary Pubh <br /> My commissio expires: <br /> EXEMPT TRANSACTIONS <br /> Page 6 Form AG3-Exempt <br /> <br /> HA-2004-1(N) <br /> <br />