EXHIBIT 10.44
Published on March 14, 2007
Exhibit 10.44
INDEMNIFICATION AGREEMENT dated as of , 2007
between
California Water Service Group (the company),
and (Indemnitee)
WHEREAS, the board of directors has determined that the ability to attract and retain
qualified persons as directors and officers is in the best interests of the companys stockholders
and that the company should act to assure such persons that there will be adequate certainty of
protection through insurance and indemnification against risks of claims and actions against them
arising out of their service to and activities on behalf of the company; and
WHEREAS, the companys certificate of incorporation provides for the elimination of
liability of the directors of the company to the fullest extent permitted by Delaware law, and
further provides for indemnification of any person who is or was a party or is threatened to be
made a party to any proceeding by reason of the fact that such person is or was an agent of the
corporation to the fullest extent permitted by Section 145 of the Delaware General Corporation Law,
and the company wishes to clarify and enhance the rights and obligations of the company and
Indemnitee with respect to indemnification; and
WHEREAS, in order to induce and encourage highly experienced and capable persons such as
Indemnitee to serve and continue to serve as directors and officers of the company and in any other
capacity with respect to the company, and to otherwise promote the desirable end that such persons
will resist what they consider unjustified lawsuits and claims made against them in connection with
the good faith performance of their duties to the company, with the knowledge that certain costs,
judgments, penalties, fines, liabilities and expenses incurred by them in their defense of such
litigation are to be borne by the company and they will receive the maximum protection against such
risks and liabilities as may be afforded by law, the board of directors of the company has
determined that the following Agreement is reasonable and prudent to promote and ensure the best
interests of the company and its stockholders; and
WHEREAS, the company desires to have Indemnitee continue to serve as a director or officer of
the company and in such other capacity with respect to the company as the company may request, as
the case may be, free from undue concern for unpredictable, inappropriate or unreasonable legal
risks and personal liabilities by reason of Indemnitee acting in good faith in the performance of
Indemnitees duty to the company; and Indemnitee desires to continue so to serve the company,
provided, and on the express condition, that he or she is furnished with the indemnity set forth
hereinafter;
Now, therefore, in consideration of Indemnitees continued service as a director or
officer of the company, the parties hereto agree as follows:
1. Service by Indemnitee. Indemnitee will serve and/or continue to serve as a
director or officer of the company faithfully and to the best of Indemnitees ability so long as
Indemnitee is duly elected or appointed and until such time as Indemnitee is removed as permitted
by law or tenders a resignation in writing. This Agreement shall not impose any obligation on the
company to continue Indemnitees service to the company beyond any period otherwise required by law
or by other agreements of the parties, if any.
2. Indemnification. The company shall indemnify Indemnitee to the fullest extent
permitted by the Delaware General Corporation Law in effect on the date hereof or as such law may
from time to time be amended (but, in the case of any such amendment, only to the extent that such
amendment permits the company to provide broader indemnification rights than said law permitted the
company to provide prior to such amendment). Without diminishing the scope of the indemnification
provided by this Section, the rights of indemnification of Indemnitee provided hereunder shall
include but shall not be limited to those rights hereinafter set forth, except that no
indemnification shall be paid to Indemnitee:
(a) to the extent expressly prohibited by Delaware law or the by-laws of the company;
(b) for which payment is actually made to Indemnitee under a valid and collectible insurance
policy or under a valid and enforceable indemnity clause, by-law or agreement of the company
or any other company or organization on whose board Indemnitee serves at the request of the
company, except in respect of any indemnity exceeding the payment under such insurance,
clause, by-law or agreement;
(c) in connection with an action, suit or Proceeding (defined below), or part thereof
(including claims and counterclaims) initiated by Indemnitee, except a judicial Proceeding
or arbitration pursuant to Section 10 to enforce rights under this Agreement, unless the
action, suit or proceeding (or part thereof) was authorized by the board of directors of the
company;
(d) with respect to any action, suit or Proceeding brought by or on behalf of the company
against Indemnitee that is authorized by the board of directors of the company, except as
provided in Sections 4, 5 and 6 below.
3. Action or Proceedings Other than an Action by or in the Right of the Company.
Except as limited by Section 2 above, Indemnitee shall be entitled to the indemnification rights
provided in this Section if Indemnitee is a party or is threatened to be
made a party to any Proceeding (other than an action by or in the name of the company) by
reason of the fact that Indemnitee is or was a director, officer, employee or agent of the company,
or is or was serving at the request of the company as a director, officer, employee or agent or
fiduciary of any other entity (including, but not limited to, another corporation, partnership,
joint venture or trust); or by reason of anything done or not done by Indemnitee in any such
capacity. Pursuant to this Section, Indemnitee shall be indemnified against all costs, judgments,
penalties, fines, liabilities, amounts paid in settlement by or on behalf of Indemnitee, and
Expenses (defined below) actually and reasonably incurred by Indemnitee in connection with such
Proceeding, if Indemnitee acted in good faith and in a manner he reasonably believed to be in or
not opposed to the best interests of the company, and with respect to any criminal Proceeding, had
no reasonable cause to believe his or her conduct was unlawful.
4. Indemnity in Proceedings by or in the Name of the Company. Except as limited by
Section 2 above, Indemnitee shall be entitled to the indemnification rights provided in this
Section if Indemnitee was or is a party or is threatened to be made a party to any Proceeding
brought by or in the name of the company to procure a judgment in its favor by reason of the fact
that Indemnitee is or was a director, officer, employee or agent or fiduciary of the company, or by
reason of anything done or not done by Indemnitee in any such capacity. Pursuant to this Section,
Indemnitee shall be indemnified against all costs, judgments, penalties, fines, liabilities,
amounts paid in settlement by or on behalf of Indemnitee, and Expenses actually and reasonably
incurred by Indemnitee in connection with such Proceeding if Indemnitee acted in good faith and in
a manner Indemnitee reasonably believed to be in or not opposed to the best interests of the
company; provided, however, that no such indemnification shall be made in respect of any claim,
issue, or matter as to which Delaware law expressly prohibits such indemnification by reason of any
adjudication of liability of Indemnitee to the company, unless and only to the extent that the
Court of Chancery of the State of Delaware or the court in which such action or suit was brought
shall determine upon application that, despite the adjudication of liability but in view of all the
circumstances of the case, Indemnitee is entitled to indemnification for such costs, judgments,
penalties, fines, liabilities and Expenses as such court shall deem proper.
5. Indemnification for Costs, Charges and Expenses of Successful Party.
Notwithstanding the limitations of Section 2(d), 3 and 4 above, to the extent that Indemnitee has
been successful, on the merits or otherwise, in whole or in part, in defense of any action, suit or
proceeding (including an action, suit or Proceeding brought by or on behalf of the company) or in
defense of any claim, issue or matter therein, including, without limitation, the dismissal of any
action without prejudice, or if it is ultimately determined that Indemnitee is otherwise entitled
to be indemnified against Expenses, Indemnitee shall be indemnified against all Expenses actually
and reasonably incurred in connection therewith.
6. Partial Indemnification. If Indemnitee is entitled under any provision of this
Agreement to indemnification by the company for some or a portion of the costs, judgments,
penalties, fines, liabilities or Expenses actually and reasonably incurred in
connection with any action, suit or Proceeding (including an action, suit or Proceeding
brought by or on behalf of the company), but not, however, for all of the total amount thereof, the
company shall nevertheless indemnify Indemnitee for the portion of such costs, judgments,
penalties, fines, liabilities and Expenses actually and reasonably incurred to which Indemnitee is
entitled.
7. Indemnification for Expenses of a Witness. Notwithstanding any other provision of
this Agreement, to the maximum extent permitted by applicable law, Indemnitee shall be entitled to
indemnification against all Expenses actually and reasonably incurred or suffered by Indemnitee or
on Indemnitees behalf if Indemnitee appears as a witness or otherwise incurs legal expenses as a
result of or related to Indemnitees service as a director or officer of the company, in any
threatened, pending or completed legal, administrative, investigative or other Proceeding or matter
to which Indemnitee neither is, nor is threatened to be made, a party.
8. Determination of Entitlement to Indemnification. Upon written request by
Indemnitee for indemnification pursuant to Sections 3, 4, 5, 6 or 7, the entitlement of Indemnitee
to indemnification, to the extent not provided pursuant to the terms of this Agreement, shall be
determined by the following person or persons who shall be empowered to make such determination:
(a) the board of directors of the company by a majority vote of Disinterested Directors (defined
below), whether or not such majority constitutes a quorum; (b) a committee of Disinterested
Directors designated by a majority vote of such directors, whether or not such majority constitutes
a quorum; (c) if there are no Disinterested Directors, or if the Disinterested Directors so direct,
by Independent Counsel (defined below) in a written opinion to the board of directors, a copy of
which shall be delivered to Indemnitee; or (d) the stockholders of the company. Such Independent
Counsel shall be selected by the board of directors and approved by Indemnitee. Notwithstanding
the foregoing, if a Change in Control (defined below) has occurred since the date of this Agreement
and the Indemnitee specifically requests in Indemnitees written request for indemnification
pursuant to Sections 3, 4, 5, 6 or 7, that such determination not be made by the parties identified
in (a) or (b) above, such determination shall be made by the party(ies) empowered to make such
determination as identified in (c) or (d). Upon failure of the board so to select such Independent
Counsel or upon failure of Indemnitee so to approve, such Independent Counsel shall be selected
upon application to a court of competent jurisdiction. Such determination of entitlement to
indemnification shall be made not later than 30 calendar days after receipt by the company of a
written request for indemnification. Such request shall include documentation or information which
is necessary for such determination and which is reasonably available to Indemnitee. Any Expenses
incurred by Indemnitee in connection with a request for indemnification or payment of Expenses
hereunder, under any other agreement, any provision of the companys by-laws or any directors and
officers liability insurance, shall be borne by the company. The company hereby indemnifies
Indemnitee for any such Expense and agrees to hold Indemnitee harmless therefrom irrespective of
the outcome of the determination of Indemnitees entitlement to indemnification. If the person
making such determination shall determine that Indemnitee is entitled to indemnification as to part
(but not all) of the application for
indemnification, such person shall reasonably prorate such partial indemnification among the
claims, issues or matters at issue at the time of the determination.
9. Presumptions and Effect of Certain Proceedings. The secretary of the company
shall, promptly upon receipt of Indemnitees request for indemnification, advise in writing the
board of directors or such other person or persons empowered to make the determination as provided
in Section 8 that Indemnitee has made such request for indemnification. Upon making such request
for indemnification, Indemnitee shall be presumed to be entitled to indemnification hereunder, and
the company shall have the burden of proof in making any determination contrary to such
presumption. If the person or persons so empowered to make such determination shall have failed to
make the requested determination with respect to indemnification within 30 calendar days after
receipt by the company of such request, a requisite determination of entitlement to indemnification
shall be deemed to have been made, and Indemnitee shall be absolutely entitled to such
indemnification, absent actual and material fraud in the request for indemnification. The
termination of any Proceeding described in Sections 3 or 4 by judgment, order, settlement or
conviction, or upon a plea of nolo contendere or its equivalent, shall not, of itself: (a) create
a presumption that Indemnitee did not act in good faith and in a manner which Indemnitee reasonably
believed to be in or not opposed to the best interests of the company, or, with respect to any
criminal Proceeding, that Indemnitee had reasonable cause to believe that Indemnitees conduct was
unlawful; or (b) otherwise adversely affect the rights of Indemnitee to indemnification except as
may be provided herein.
10. Remedies of Indemnitee in Cases of Determination not to Indemnify or to Pay
Expenses. In the event that a determination is made that Indemnitee is not entitled to
indemnification hereunder or if payment has not been timely made following a determination of
entitlement to indemnification pursuant to Sections 8 and 9, or if Expenses are not paid pursuant
to Section 15, Indemnitee shall be entitled to final adjudication in a court of competent
jurisdiction of entitlement to such indemnification or payment. Alternatively, Indemnitee at
Indemnitees option may seek an award in an arbitration to be conducted by a single arbitrator
pursuant to the rules of the American Arbitration Association, such award to be made within sixty
days following the filing of the demand for arbitration. The company shall not oppose Indemnitees
right to seek any such adjudication or award in arbitration or any other claim. The determination
in any such judicial Proceeding or arbitration shall be made de novo on the merits, and Indemnitee
shall not be prejudiced by reason of a determination (if so made) pursuant to Sections 8 or 9 that
Indemnitee is not entitled to indemnification. If a determination is made or deemed to have been
made pursuant to the terms of Section 8 or 9 that Indemnitee is entitled to indemnification, the
company shall be bound by such determination and is precluded from asserting that such
determination has not been made or that the procedure by which such determination was made is not
valid, binding and enforceable. The company further agrees to stipulate in any such court or
before any such arbitrator that the company is bound by all the provisions of this Agreement and is
precluded from making any assertions to the contrary. If the court or arbitrator shall determine
that Indemnitee is entitled to any indemnification or payment of Expenses hereunder, the company
shall pay all Expenses
actually and reasonably incurred by Indemnitee in connection with such adjudication or award
in arbitration (including, but not limited to, any appellate Proceedings).
11. Other Rights to Indemnification. Indemnification and payment of Expenses provided
by this Agreement shall not be deemed exclusive of any other rights to which
Indemnitee may now or
in the future be entitled under any provision of the by-laws or other organizational documents of
the company, vote of stockholders or Disinterested Directors, provision of law, agreement or
otherwise.
12. Expenses to Enforce Agreement. In the event that Indemnitee is subject to or
intervenes in any Proceeding in which the validity or enforceability of this Agreement is at issue
or seeks an adjudication or award in arbitration to enforce Indemnitees rights under, or to
recover damages for breach of, this Agreement, Indemnitee, if Indemnitee prevails in whole or in
part in such action, shall be entitled to recover from the company and shall be indemnified by the
company against any actual Expenses incurred by Indemnitee.
13. Continuation of Indemnity. All agreements and obligations of the company
contained herein shall continue during the period Indemnitee is a director, officer, employee or
agent of the company or is serving at the request of the company as a director, officer, employee
or agent or fiduciary of any other entity (including, but not limited to, another corporation,
partnership, joint venture or trust) of the company and shall continue thereafter with respect to
any possible claims based on the fact that Indemnitee was a director, officer employee or agent of
the company or was serving at the request of the company as a director, officer, employee or agent
or fiduciary of any other entity (including, but not limited to, another corporation, partnership,
joint venture or trust). This Agreement shall be binding upon all successors and assigns of the
company (including any transferee of all or substantially all of its assets and any successor by
merger or operation of law) and shall inure to the benefit of the heirs, personal representatives
and estate of Indemnitee.
14. Notification and Defense of Claim. Promptly after receipt by Indemnitee of
notice of any Proceeding, Indemnitee will, if a claim in respect thereof is to be made against the
company under this Agreement, notify the company in writing of the commencement thereof; but the
omission so to notify the company will not relieve it from any liability that it may have to
Indemnitee. Notwithstanding any other provision of this Agreement, with respect to any such
Proceeding of which Indemnitee notifies the company:
(a) The company shall be entitled to participate therein at its own expense; and
(b) Except as otherwise provided in this Section 14(b), to the extent that it may wish, the
company, jointly with any other indemnifying party similarly notified, shall be entitled to
assume the defense thereof, with counsel satisfactory to Indemnitee. After notice from the
company to Indemnitee of its election so to assume the defense thereof, the company shall
not be liable to Indemnitee under this Agreement for any expenses of counsel subsequently
incurred by Indemnitee in connection with the defense thereof except as otherwise provided
below. Indemnitee shall have the right to employ
Indemnitees own counsel in such Proceeding, but the fees and expenses of such counsel
incurred after notice from the company of its assumption of the defense thereof shall be at
the expense of Indemnitee unless (i) the employment of counsel by Indemnitee has been
authorized by the company, (ii) Indemnitee shall have reasonably concluded that there may be
a conflict of interest between the company and Indemnitee in the conduct of the defense of
such action or (iii) the company shall not within 60 calendar days of
receipt of notice from
Indemnitee in fact have employed counsel to assume the defense of the action, in each of
which cases the fees and expenses of Indemnitees counsel shall be at the expense of the
company. The company shall not be entitled to assume the defense of any Proceeding brought
by or on behalf of the company or as to which Indemnitee shall have made the conclusion
provided for in (ii) above; and
(c) If the company has assumed the defense of a Proceeding, the company shall not be liable
to indemnify Indemnitee under this Agreement for any amounts paid in settlement of any
Proceeding affected without the companys written consent. The company shall not settle any
Proceeding in any manner that would impose any penalty or limitation on or disclosure
obligation with respect to Indemnitee without Indemnitees written consent. Neither the
company nor Indemnitee will unreasonably withhold its consent to any proposed settlement.
15. Payment of Expenses. All Expenses incurred by Indemnitee in advance of the final
disposition of any Proceeding shall be paid by the company at the request of Indemnitee, each such
payment to be made within 20 calendar days after the receipt by the company of a statement or
statements from Indemnitee requesting such payment or payments from time to time. Indemnitees
entitlement to such Expenses shall include those incurred in connection with any Proceeding by
Indemnitee seeking a judgment in court or an adjudication or award in arbitration pursuant to this
Agreement (including the enforcement of this provision). Such statement or statements shall
reasonably evidence the expenses and costs incurred by Indemnitee in connection therewith and shall
include or be accompanied by an undertaking, in substantially the form attached as Exhibit 1, by or
on behalf of Indemnitee to reimburse such amount if it is finally determined, after all appeals by
a court of competent jurisdiction that Indemnitee is not entitled to be indemnified against such
Expenses by the company as provided by this Agreement or otherwise. Indemnitees undertaking to
reimburse any such amounts is not required to be secured.
16. Separability; Prior Indemnification Agreements. If any provision or
provisions of this Agreement shall be held to be invalid, illegal or unenforceable for any reason
whatsoever (a) the validity, legality and enforceability of the remaining provisions of this
Agreement (including without limitation, all portions of any paragraphs of this Agreement
containing any such provision held to be invalid, illegal or unenforceable, that are not by
themselves invalid, illegal or unenforceable) shall not in any way be affected or impaired thereby,
and (b) to the fullest extent possible, the provisions of this Agreement (including, without
limitation, all portions of any paragraph of this Agreement containing any such provision held to
be invalid, illegal or unenforceable, that are not themselves invalid, illegal or unenforceable)
shall be construed so as to give effect to the intent of the parties that the company provide
protection to Indemnitee to the fullest enforceable extent. This Agreement shall
supersede and replace any prior indemnification agreements entered into by and between the
company and Indemnitee and any such prior agreements shall be terminated upon execution of this
Agreement.
17. Headings; References; Pronouns. The headings of the sections of this
Agreement are inserted for convenience only and shall not be deemed to constitute part of this
Agreement or to affect the construction thereof. References herein to section numbers are to
sections of this Agreement. All pronouns and any variations thereof shall be deemed to refer to
the masculine, feminine, neuter, singular or plural as appropriate.
18. Definitions. For purposes of this Agreement:
(a) Change in Control shall be deemed to take place on the occurrence of any of the
following events: (i) any merger or consolidation of the Employer (which includes the
company and/or its Affiliates or Associates, as such terms are defined in Rule 12b-2
under the Securities Exchange Act of 1934), in which the Employer is not the surviving
organization, a majority of the capital stock of which is not owned by the stockholders of
the Employer immediately prior to such merger or consolidation; (ii) a transfer of all or
substantially all of the assets of the Employer; (iii) any other corporate reorganization in
which there is a change in ownership of the outstanding shares of the Employer wherein 30%
or more of the outstanding shares of the Employer are transferred to any Person (as that
term is used in Sections 13(d) and 14(d)(2) of the Securities Exchange Act of 1934); (iv)
the acquisition by or transfer to a Person (including all Affiliates or Associates of such
Person) of beneficial ownership (as that term is defined in Rule 13d-3 under the
Securities Exchange Act of 1934) of capital stock of the Employer if after such acquisition
or transfer such Person (and their Affiliates or Associates) is entitled to exercise 30% or
more of the outstanding voting power of all capital stock of the Employer entitled to vote
in elections of directors; or (v) the election to the board of directors of the Employer of
candidates who were not recommended for election by the board of directors of the Employer
in office immediately prior to the election, if such candidates constitute a majority of
those elected in that particular election.
(b) Disinterested Director means a director of the company who is not or was not a party
to the Proceeding in respect of which indemnification is being sought by Indemnitee.
(c) Expenses includes, without limitation, expenses incurred in connection with the
defense or settlement of any and all investigations, judicial or administrative proceedings
or appeals, attorneys fees, witness fees and expenses, fees and expenses of accountants and
other advisors, retainers and disbursements and advances thereon, the premium, security for,
and other costs relating to any bond (including cost bonds, appraisal bonds or their
equivalents), and any expenses of establishing a right to
indemnification under Sections 8, 10 and 12 above but shall not include the amount of
judgments, fines or penalties actually levied against Indemnitee.
(d) Independent Counsel means a law firm or a member of a law firm that neither is
presently nor in the past five years has been retained to represent: (i) the company or
Indemnitee in any matter material to either such party, or (ii) any other party to the
Proceeding giving rise to a claim for indemnification hereunder. Notwithstanding the
foregoing, the term Independent Counsel shall not include any person who, under the
applicable standards of professional conduct then prevailing, would have a conflict of
interest in representing either the company or Indemnitee in an action to determine
Indemnitees right to indemnification under this Agreement.
(e) Proceeding includes any threatened, pending or completed investigation, action, suit
or other proceeding, whether brought in the name of the company or otherwise, against
Indemnitee, for which indemnification is not prohibited under Sections 2(a)-(c) above and
whether of a civil, criminal, administrative or investigative nature, including, but not
limited to, actions, suits or proceedings in which Indemnitee may be or may have been
involved as a party or otherwise, by reason of the fact that Indemnitee is or was a
director, officer, employee or agent of the company, or is or was serving, at the request of
the company, as a director, officer, employee or agent or fiduciary of any other entity,
including, but not limited to, another corporation, partnership, joint venture or trust, or
by reason of anything done or not done by Indemnitee in any such capacity, whether or not
Indemnitee is serving in such capacity at the time any liability or expense is incurred for
which indemnification or reimbursement can be provided under this Agreement.
19. Other Provisions.
(a) This Agreement shall be interpreted and enforced in accordance with the laws of
Delaware.
(b) This Agreement may be executed in one or more counterparts, each of which shall for
all purposes be deemed to be an original but all of which together shall constitute one and
the same Agreement. Only one such counterpart signed by the party against whom
enforceability is sought needs to be produced as evidence of the existence of this
Agreement.
(c) This Agreement shall not be deemed an employment contract between the company and
any Indemnitee who is an officer of the company, and, if Indemnitee is an officer of the
company, Indemnitee specifically acknowledges that Indemnitee may be discharged at any time
for any reason, with or without cause, and with or without severance compensation, except as
may be otherwise provided in a separate written contract between Indemnitee and the company.
(d) Upon a payment to Indemnitee under this Agreement, the company shall be subrogated to
the extent of such payment to all of the rights of Indemnitee to recover against any person
for such liability, and Indemnitee shall execute all documents and instruments required and
shall take such other actions as may be necessary to secure such rights, including the
execution of such documents as may be necessary for the company to bring suit to enforce
such rights.
(e) No supplement, modification or amendment of this Agreement shall be binding unless
executed in writing by both parties hereto. No waiver of any of the provisions of this
Agreement shall be deemed or shall constitute a waiver of any other provisions hereof
(whether or not similar) nor shall such waiver constitute a continuing waiver.
(f) All notices, requests, demands and other communications hereunder shall be in writing
and shall be deemed to have been duly given if: (a) actually received; or (b) mailed by
certified or registered mail, postage prepaid, on the third business day after the date on
which it is so mailed. Notices, requests and demands pursuant to this Agreement shall be
provided to: the Company (to the attention of the General Counsel, at 1720 North First
Street, San Jose, CA 95112 and the Chief Financial Officer, at 1720 North First Street, San
Jose, CA 95112; with a copy to Gibson, Dunn & Crutcher LLP, One Montgomery Street, 31st
Floor, San Francisco, CA 94104.
(g) This Agreement shall be deemed to be the product of all of the parties hereto, and no
ambiguity shall be construed in favor of or against any one of the parties hereto.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement on and as of the day
and year first above written.
CALIFORNIA WATER SERVICE GROUP
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EXHIBIT 1
UNDERTAKING TO REPAY INDEMNIFICATION EXPENSES
I , agree to reimburse California Water Service Group (the company) for
all expenses paid to me by the company in connection with any Proceeding (as defined in the
Indemnification Agreement dated as of between me and the company), in the event, and to
the extent that it shall finally be determined after all appeals by a court of competent
jurisdiction that I am not entitled to be indemnified by the company for such expenses.
Signature |
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Typed Name |
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Date |
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Before me , on this day personally appeared
, known to me to be the person whose name is subscribed to the foregoing
instrument, and who, after being duly sworn, stated that the contents of said instrument is to the
best of his/her knowledge and belief true and correct and who acknowledged that he/she executed the
same for the purpose and consideration therein expressed.
GIVEN under my hand and official seal at , this day of ,
200 .
My commission expires: