Laserfiche WebLink
PROVIDER'S ACKNOWLEDGMENT <br /> Sta 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 a is the of <br /> t PROVIDER named in the foregoing instrument, and that <br /> he/she is authorized to sign said in rument on behalf of the PROVIDER, as provided in <br /> Recital E of the foregoing Agreeme and acknowledges that he/she executed said <br /> instrument as the free act and deed of the P OVIDER. <br /> Notary Public, <br /> My commission expires: <br /> EXEMPT TRANSACTIONS <br /> Page 6 Form AG3-Exempt <br /> <br /> HA-2005-1(N) <br /> <br />