!"#$%&'( )* +," #,'&'##'-". /012345064 78 +3269173424:76 78 +3269173424:76 26; (755<6:=24:769
&>-/ +!>-.#)!+>+')- *!>-(,'.'-? >-/ !"?$&>+)!@ %)>!/ "294 >A06<0B C<0D76 (:4E
#-"-,.,'- &/ /0'"'!0"% !")"+0%0-* 1"!-2"% 3&450'6 !")0-"%7 !"# $%&'('&)*+ !"# $%&'('&)*+ ,-.#*/"# ,-.#*/"# 01+.*2. 01+.*2. *33"4-+'25 6.+"78
&>.+ ->F" *'!.+ ->F" F'//&" ->F" />+" )* %'!+,
."G
F
*
+'- -)H
!"# 9"#-"#*/'"%:9""-.#*/'(.:,/5.#2 !"# 9"#-"#*/'"%:9""-.#*/'(.:,/5.#201+.*2. 01+.*2. *33"4-+'25 6.+"78
->F" )* ()!#)!>+')-I())#"!>+'J"I)+,"!.
."(I(/> !"?'.+!>+')- -)H
+'- -)H
->F" )* >$+,)!'K"/ !"#!"."-+>+'J"
'H ($!!"-+ >.."+.
>F)$-+IJ>&$"
(29L 76 ,26; (29L 24 %26M N.2A:6O9I(<33064P )4L039 )4&),4-0,# 1!899:;< =9 .>9?:< @>A8:7
!02Q "94240 J0L:=Q09 )4L039 0'@,#-.,'-# (034:8:=2409 78 /0179:4 78 /0179:4 N+:50 /0179:4B 04=HP .0=<3:4:09 N.47=M9B %76;9B F<4<2Q *<6;9B 04=HP %<9:6099 '6A09450649 NR734L 78 9L2309B 78 9L2309B 04=HP '69<326=0 #7Q:=:09 N(29L .<3306;03 J2Q<0P )4L039 - &-"%
"##,-#
''H ($!!"-+ &'>%'&'+'". %&"'# "'( )"*"+%,# (30;:4 (23; /0S49 &726I9 N,7<9:6OB 2<47B 04=P )4L039
>F)$-+IJ>&$"
0'@,#-.,'- (,+-# %<9:6099I '69<326=0 /0S49 )4L039 - &-"%
%0"+0%0-0,#
-&-"% 3&450'6 !")0-"% 1-=<>A "BB:A %C>DCAC
NAME & SIGNATURE OF OPERATOR
SUBSCRIBED AND SWORN to before me this _______ day of __________ at ________________________________________________. Affiant exhibited to me his _____________________ issued at _____________________ on ____________________________________.
Doc No.
: ________
Page No.
: ________
Book No.
: ________
Series of
: ________