NY Notary Form

State of New York
County of

Notary Public Information

Name of Notary Public:

Notary Public License Number:

Commission Expiration Date:

Notary Public Address:

Phone Number:

Email Address:

Signers Information

Name of Signer:

Address of Signer:

Identification Type:

Identification Number:

Date of Birth:

Affirmation/Certification

I, the undersigned, do hereby declare that the individual(s) named above personally appeared before me on this Dateand provided satisfactory proof of identity.

Signature of Notary Public

Date:

Seal

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