The undersigned hereby certify that he was associated as partner (or as .................................................................................

..................................................................................................................................................................................................................................................................................................) with (state names of parties or associates)

............................................................................................................................................................................................

............................................................................................................................................................................................

for the purpose of ................................................................................................................................................................

............................................................................................................................................................................................

............................................................................................................................................................................................

in the municipality of Turner State of Maine, under the name .................................................................................................

............................................................................................................................................................................................

that he has withdrawn from such mercantile enterprise.

Name Residence

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.......................................................................ss, ..................................................................................A.D. 20...............

Then personally appeared ..................................................................................................................................................

and made oath to the foregoing certificate, that the same is true.

Before me,

................................................................................................

Notary Public