City of __________
County of __________:
ss __________ (name of individual), who affixed (his) (her) signature below in my presence, came before me, a ________ (title), in and for the aforesaid County and State, this ______ day of ______, 19-, and established (his) (her) identity to my satisfaction.
My commission expires __________.
__________________
(signature)
If the request follows inquiry under § 16.3 , this should be indicated in the request for access in order to facilitate processing.
24 C.F.R. §16.4