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PROVIDER'S ACKNOWLEDGMENT <br /> State of <br /> SS. <br /> County o ) <br /> On this da of ,before me personally <br /> appeared , to me personally known, who being by me <br /> duly sworn, did say that he/she is a of <br /> the PR VIDER named in the foregoing instrument, and that <br /> be/she is authorized to sign said instru ent on behalf of the PROVIDER, as provided in <br /> Recital E of the foregoing Agreement, d acknowledges that be/she executed said <br /> instrument as the free act and deed of the PR IDER. <br /> Notary Public, <br /> My commission expi <br /> EXEMPT TRANSACTIONS <br /> Page 6 Form AG3-Exempt <br /> <br /> HA-2004-2005-2(A) <br /> <br />