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<br />"., - I:''' <br /> <br />~ <br /> <br />,- <br /> <br />e <br /> <br />WITNESS THE EXECUTION HEREOF on this the <br /> <br />day of <br /> <br />, A.D., 19. <br /> <br />OWner: <br /> <br />Address <br />& Zip <br /> <br />By: <br /> <br />Title: <br /> <br />ACKNOWLEDGMENT <br /> <br />THE STATE OF TEXAS X <br />COUNTY OF HARRIS X <br /> <br />Before me, the undersigned authority, on this day personally <br /> <br />appeared <br /> <br />, known to me to <br /> <br />be the person whose name is subscribed to the foregoing instrument, <br /> <br />and acknowledged to me that he executed the same for the purposes <br />and consideration therein expressed. <br /> <br />Given under my hand and seal of office on this the <br /> <br />day of <br /> <br />, A.D., 19 <br /> <br />Notary Public in and for Harris <br />County, Texas <br />