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STATE OF . IL <br /> COUNTY OF <br /> I, a Notary Public in and for said county, do hereby certify that <br /> Notary Name <br /> Insert name of Individuals signing on behalf of PRINCIPAL <br /> who is/are each personally known to me to be the same person(s)whose name(s)is/are subscribed to the foregoing instrument on behalf <br /> of PRINCIPAL, appeared before me this day in person and acknowledged respectively,that he/she/they signed and delivered said <br /> instrument freely and voluntarily for the uses and purposes therein set forth. <br /> Given under my hand and notarial seal this day of <br /> ' Day Month,Year <br /> Notary Public Signature& Date <br /> (SEAL) <br /> Date commission expires <br /> ' SURETY <br /> Name of Surety Title <br /> ' Selective Insurance Company of America By: <br /> Connie Smlth, Attorney-in-Fact <br /> ' STATE OF /Y WI <br /> COUNTY OF St, Croix <br /> ' I Mol.li J. Hansen a Notary Public in and for said county, do hereby certify that <br /> Notary Name <br /> Connie Smith <br /> ' Insert name of Individuals signing on behalf of SURETY <br /> who is/are each personally known to me to be the same person(s)whose name(s)is/are subscribed to the foregoing instrument on behalf <br /> of SURETY, appeared before me this day in person and acknowledged respectively,that he/she/they signand delivered said instrument <br /> freely and voluntarily for the uses and purposes therein set forth. <br /> Given under my hand aWindtarial I thip 20th day of November, 2023 <br /> Day Month,Year <br /> Notary P blit Signature&Dat 11 0/ 23 <br /> y <br /> M S,yN <br /> N <br /> 20-Oct-2024 <br /> Y!1) O Date commission expires <br /> � ��lF�F�\��` <br /> ' Approved this day of November, 2023 <br /> Day Month,Year <br /> ' Attest: <br /> Local Public Agency Clerk Signature& Date Awarding Authority <br />' Awarding Authority Signature&Date <br />' Local Public Agency Type Clerk <br />' Completed 11/16/23 Page 2 of 2 BLR 12321 (Rev.01/19/23) <br />