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<div class=3DSection1>

<p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'><span
style=3D'font-size:14.0pt;color:maroon'>PARENTAL CONSENT, RELEASE AND WAIVE=
R OF
LIABILITY,<o:p></o:p></span></p>

<p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'><span
style=3D'font-size:14.0pt;color:maroon'>ASSUMPTION OF RISK, AND IDEMNITY
AGREEMENT<o:p></o:p></span></p>

<p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'><span
style=3D'font-size:14.0pt;color:maroon'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'><span
style=3D'font-size:14.0pt;color:maroon'><span
style=3D'mso-spacerun:yes'>&nbsp;</span>___________________________________=
_____________________________________<o:p></o:p></span></p>

<p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'><span
style=3D'font-size:9.0pt;color:#333333'>DESCRIPTION AND LOCATION OF EVENTS<=
o:p></o:p></span></p>

<p class=3DMsoNormal align=3Dcenter style=3D'text-align:center'><span
style=3D'font-size:9.0pt;color:gray'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal><span style=3D'font-size:9.0pt;color:gray'><o:p>&nbsp;=
</o:p></span></p>

<p class=3DMsoNormal><span style=3D'font-size:9.0pt;color:#333333'>IN CONSI=
DERATION
of my minor child (&#8220;the Minor&#8221;) being permitted to participate =
in
any way in the EVENT(S) and/or being permitted<o:p></o:p></span></p>

<p class=3DMsoNormal><span class=3DGramE><span style=3D'font-size:9.0pt;col=
or:#333333'>to</span></span><span
style=3D'font-size:9.0pt;color:#333333'> enter for any purpose any RESTRICT=
ED
AREA(S) (defined to be any area which requires special authorization,
credentials or<o:p></o:p></span></p>

<p class=3DMsoNormal><span class=3DGramE><span style=3D'font-size:9.0pt;col=
or:#333333'>permission</span></span><span
style=3D'font-size:9.0pt;color:#333333'> to enter or any area to which admi=
ssion
by the general public is restricted or prohibited), I agree:<o:p></o:p></sp=
an></p>

<p class=3DMsoNormal><span style=3D'font-size:9.0pt;color:#333333'><o:p>&nb=
sp;</o:p></span></p>

<p class=3DMsoNormal><span style=3D'font-size:9.0pt;color:#333333'><span
style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp; </span><o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt;text-indent:-.25in;mso-li=
st:l0 level1 lfo2;
tab-stops:list 47.25pt'><![if !supportLists]><span style=3D'font-size:9.0pt;
color:#333333'><span style=3D'mso-list:Ignore'>1.<span style=3D'font:7.0pt =
"Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span></span><![endif]><span style=3D'font-size:9.0pt;color:#333333=
'>I
know the nature of the EVENT(S) and the Minor&#8217;s experience and
capabilities, and believe the Minor to be qualified to<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>Participate in the Event(s).<span
style=3D'mso-spacerun:yes'>&nbsp; </span>I will inspect the premises, facil=
ities,
and equipment to be used, or with which the Minor may<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>Come in contact.<span style=3D'mso-spacerun:yes'>&nbsp; </sp=
an>IF
I OR THE MINOR BELIEVE ANYTHING IS UNSAFE, I WILL INSTRUCT THE MINOR TO <o:=
p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>IMMEDIATELY LEAVE THE RESTRICTED AREA AND REFUSE TO PARTICIP=
ATE
FURTHER IN THE EVENT(S).<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt;text-indent:-.25in;mso-li=
st:l0 level1 lfo2;
tab-stops:list 47.25pt'><![if !supportLists]><span style=3D'font-size:9.0pt;
color:#333333'><span style=3D'mso-list:Ignore'>2.<span style=3D'font:7.0pt =
"Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span></span><![endif]><span style=3D'font-size:9.0pt;color:#333333=
'>I
FULLY UNDERSTAND and will instruct the Minor that:<span
style=3D'mso-spacerun:yes'>&nbsp; </span>(a)<span style=3D'mso-spacerun:yes=
'>&nbsp;
</span>THE ACTIVITES OF THE EVENT(S) ARE VERY<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>DANGEROUS and participation in the Event(s) and/or entry into
Restricted Areas involves RISKS AND DANGERS OF<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARAL=
YSIS
AND DEATH (&#8220;RISKS&#8221;); (b) <o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>these</span></span><span
style=3D'font-size:9.0pt;color:#333333'> Risks and dangers may be caused by=
 the
Minor&#8217;s own actions, or inactions, the actions or inaction of others
participating<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>in</span></span><span style=3D'font=
-size:
9.0pt;color:#333333'> the Event(s), the rules of the Events(s), the conditi=
on
and layout of the premises and equipment, and/or THE NEGLIGENCE <o:p></o:p>=
</span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>OF THE &#8220;RELEASEES&#8221; NAMED BELOW; (c) there may be
OTHER RISKS NOT KNOWN TO ME or that are not readily<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>Foreseeable at this time; (d) THE SOCIAL AND ECONOMIC LOSSES
and/or damages that could result from the Risk(s)<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>COULD BE SEVERE AND COULD PERMANENTAL CHANGE THE MINOR&#8217=
;S
FUTURE.<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt;text-indent:-.25in;mso-li=
st:l0 level1 lfo2;
tab-stops:list 47.25pt'><![if !supportLists]><span style=3D'font-size:9.0pt;
color:#333333'><span style=3D'mso-list:Ignore'>3.<span style=3D'font:7.0pt =
"Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span></span><![endif]><span style=3D'font-size:9.0pt;color:#333333=
'>I
consent to the Minor&#8217;s participation in the Event(s) and/or any entry
into restricted areas and HEREBY ACCEPT AND<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>ASSUME ALL SUCH RISKS, KNOWN AND UNKNOWN, AND ASSUME ALL
RESPONSIBILITY FOR THE LOSSES,<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>COSTS AND/OR DAMAGES FOLLOWING SUCH INJURY, DISABILITY,
PARALYSIS OR DEATH, EVEN IF CAUSED,<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>IN WHOLE OR IN PART, BY THE NEGLIGENCE OF <span class=3DGram=
E>THE<span
style=3D'mso-spacerun:yes'>&nbsp; </span>&#8220;</span>RELEASEES&#8221; NAM=
ED
BELOW.<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt;text-indent:-.25in;mso-li=
st:l0 level1 lfo2;
tab-stops:list 47.25pt'><![if !supportLists]><span style=3D'font-size:9.0pt;
color:#333333'><span style=3D'mso-list:Ignore'>4.<span style=3D'font:7.0pt =
"Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span></span><![endif]><span style=3D'font-size:9.0pt;color:#333333=
'>I
HEREBY RELEASE, DISCHARGE AND COVENANT NOT TO SUE the promoters, participan=
ts,
racing associations,<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>sanctioning</span></span><span
style=3D'font-size:9.0pt;color:#333333'> organizations or any subdivision
thereof, track operators, track owners, officials, car owners, drivers, pit=
<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>Crews, rescue personnel, any persons in any Restricted Area,
sponsors, advertisers, owners and lessees of premises<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>used</span></span><span style=3D'fo=
nt-size:
9.0pt;color:#333333'> to conduct the Event(s), premises or event inspectors,
surveyors, underwriters, consultants and other persons or<o:p></o:p></span>=
</p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>entities</span></span><span
style=3D'font-size:9.0pt;color:#333333'> who give recommendations, directio=
ns, or
instructions or engage in risk evaluation or loss control activities <o:p><=
/o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>regareding</span></span><span
style=3D'font-size:9.0pt;color:#333333'> the premises or Event(s) and each =
of
them, their directors, officers, agents, employees, representatives, <o:p><=
/o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>owners</span></span><span
style=3D'font-size:9.0pt;color:#333333'>, members, affiliates, successors a=
nd
assigns, all for the purposes herein referred to as &#8220;Releasees,
&#8220;FROM ALL<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>LIABILITY TO ME, THE MINOR, my and the minor&#8217;s personal
representatives, assigns, heirs, and next of kin, FOR ANY<o:p></o:p></span>=
</p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>AND ALL CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON ACCOUNT OF ANY
INJURY TO ME OR THE MINOR, <o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>Including, but not limited to, death or damage to property,
CAUSED OR ALLEGED TO BE CAUSED, IN WHOLE OR IN<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>PART, BY THE NEGLIGENCE OF THE
&#8220;RELEASEES&#8221; OR OTHERWISE.</span></span><span style=3D'font-size=
:9.0pt;
color:#333333'><o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt;text-indent:-.25in;mso-li=
st:l0 level1 lfo2;
tab-stops:list 47.25pt'><![if !supportLists]><span style=3D'font-size:9.0pt;
color:#333333'><span style=3D'mso-list:Ignore'>5.<span style=3D'font:7.0pt =
"Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span></span><![endif]><span style=3D'font-size:9.0pt;color:#333333=
'>If,
despite this release, I, the Minor, or anyone on the Minor&#8217;s behalf,
makes a claim against any of the &#8220;Releasees&#8221;<o:p></o:p></span><=
/p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>named</span></span><span
style=3D'font-size:9.0pt;color:#333333'> above, I AGREE TO DEFEND, INDEMNIF=
Y AND
SAVE AND HOLD HARMLESS THE RELEASEES and each<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span class=3DGramE><span
style=3D'font-size:9.0pt;color:#333333'>of</span></span><span style=3D'font=
-size:
9.0pt;color:#333333'> them from ANY LITIGATION EXPENSES, ATTORNEY FEES, LOS=
S,
LIABILITY, DAMAGE, OR COST THEY MAY<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>INCUR DUE TO THE CLAIM MADE AGAINST ANY OF THE
&#8220;RELEASEES&#8221; NAMED ABOVE, WHETHER THE CLAIM<o:p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'>IS BASED ON THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.<o:=
p></o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt'><span style=3D'font-size=
:9.0pt;
color:#333333'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal style=3D'margin-left:47.25pt;text-indent:-.25in;mso-li=
st:l0 level1 lfo2;
tab-stops:list 47.25pt'><![if !supportLists]><span style=3D'font-size:9.0pt;
color:#333333'><span style=3D'mso-list:Ignore'>6.<span style=3D'font:7.0pt =
"Times New Roman"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span></span><![endif]><span style=3D'font-size:9.0pt;color:#333333=
'>I
sign the agreement on my own behalf and on behalf of the Minor.<o:p></o:p><=
/span></p>

<p class=3DMsoNormal><span style=3D'font-size:9.0pt;font-family:Arial;color=
:#4D4D4D'><o:p>&nbsp;</o:p></span></p>

<p class=3DMsoNormal><b style=3D'mso-bidi-font-weight:normal'><span
style=3D'font-size:9.0pt;font-family:Arial;color:#333333'><o:p>&nbsp;</o:p>=
</span></b></p>

<p class=3DMsoNormal><b style=3D'mso-bidi-font-weight:normal'><span
style=3D'font-size:9.0pt;color:#333333'>I HAVE READ THIS PARENTAL CONSENT,
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY<o:p></o:=
p></span></b></p>

<p class=3DMsoNormal><b style=3D'mso-bidi-font-weight:normal'><span
style=3D'font-size:9.0pt;color:#333333'>AGREEMENT, UNDERSTAND THAT BY SIGNI=
NG IT
I GIVE UP SUBSTANTIAL RIGHTS I AND/OR THE MINOR WOULD <o:p></o:p></span></b=
></p>

<p class=3DMsoNormal><b style=3D'mso-bidi-font-weight:normal'><span
style=3D'font-size:9.0pt;color:#333333'>OTHERWISE HAVE TO RECOVER DAMAGES F=
OR
LOSSES OCCASIONED BY THE RELEASEES&#8221; FAULT, AND SIGN IT<o:p></o:p></sp=
an></b></p>

<p class=3DMsoNormal><b style=3D'mso-bidi-font-weight:normal'><span
style=3D'font-size:9.0pt;color:#333333'>VOLUNTARILY AND WITHOUT INDUCEMENT.=
</span></b><u><span
style=3D'font-size:9.0pt;color:#999999'><span
style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp;&nbsp; </span><o:p></o:p></spa=
n></u></p>

<p class=3DMsoNormal><u><span style=3D'font-size:9.0pt;color:#999999'><o:p>=
<span
 style=3D'text-decoration:none'>&nbsp;</span></o:p></span></u></p>

<p class=3DMsoNormal><u><span style=3D'font-size:9.0pt;color:#999999'><o:p>=
<span
 style=3D'text-decoration:none'>&nbsp;</span></o:p></span></u></p>

<p class=3DMsoNormal><u><span style=3D'font-size:9.0pt;color:#999999'><o:p>=
<span
 style=3D'text-decoration:none'>&nbsp;</span></o:p></span></u></p>

<p class=3DMsoNormal><span style=3D'font-size:10.0pt;color:#999999'>_______=
_______________________<span
style=3D'mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp; </span>___________________________<o:p></o:p></span></p>

<p class=3DMsoNormal><span style=3D'font-size:10.0pt'>Name of Minor Partici=
pant <span
style=3D'mso-tab-count:3'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp; </span><st1:place
w:st=3D"on"><st1:PlaceName w:st=3D"on">Pit</st1:PlaceName> <st1:PlaceType w=
:st=3D"on">Pass</st1:PlaceType></st1:place>
Number <o:p></o:p></span></p>

<p class=3DMsoNormal><u><span style=3D'font-size:9.0pt;color:#999999'><o:p>=
<span
 style=3D'text-decoration:none'>&nbsp;</span></o:p></span></u></p>

<p class=3DMsoNormal><u><span style=3D'font-size:9.0pt;color:#999999'><o:p>=
<span
 style=3D'text-decoration:none'>&nbsp;</span></o:p></span></u></p>

<p class=3DMsoNormal><u><span style=3D'font-size:9.0pt;color:#999999'><span
style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=
&nbsp;&nbsp;&nbsp;&nbsp;
</span>I HAVE READ THIS RELEASE<span
style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span></u><span style=3D'font-size:9.0pt;color:#999999'><span
style=3D'mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>______________________________________=
__<span
style=3D'mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>____________________<o:p><=
/o:p></span></p>

<p class=3DMsoNormal><span style=3D'font-size:10.0pt'>Signature of Parent o=
r Legal
Guardian <span style=3D'mso-tab-count:2'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>Printed
Name of Parent or Legal Guardian <span style=3D'mso-tab-count:2'>&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>Date
<o:p></o:p></span></p>

<p class=3DMsoNormal><span style=3D'font-size:10.0pt'><o:p>&nbsp;</o:p></sp=
an></p>

<p class=3DMsoNormal><u><span style=3D'font-size:9.0pt;color:#999999'><span
style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span>I HAVE READ THIS RELEASE<span
style=3D'mso-spacerun:yes'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;=
&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
</span></span></u><span style=3D'font-size:9.0pt;color:#999999'><span
style=3D'mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp; </span>________________________________________<span
style=3D'mso-tab-count:1'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>____________________<o:p><=
/o:p></span></p>

<p class=3DMsoNormal><span style=3D'font-size:10.0pt'>Signature of Witness<=
span
style=3D'mso-tab-count:4'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span=
>Printed
Name of Witness<span style=3D'mso-tab-count:4'>&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbs=
p;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&=
nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </span>Date<o:p></o:p=
></span></p>

<p class=3DMsoNormal><span style=3D'font-size:10.0pt'><o:p>&nbsp;</o:p></sp=
an></p>

<p class=3DMsoNormal><o:p>&nbsp;</o:p></p>

<p class=3DMsoNormal><o:p>&nbsp;</o:p></p>

</div>

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