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Dated: , 20 . <br /> } SS. <br /> STATE OF MINNESOTA <br /> COUNTY OF <br /> On this day of , 20_, before me, a Notary Public within and <br /> for said County, personally appeared , , to me <br /> known as the person described in and who executed the foregoing instrument, who stated <br /> that they are the owners of the property this permit applies to, and acknowledged that they <br /> executed the same as their free act and deed. <br /> Notary Public <br />