Document:

Exhibit
10.4

    Form of

    RELIV’
INTERNATIONAL, INC.

    RESTRICTED STOCK
AGREEMENT

     

    THIS RESTRICTED STOCK
AGREEMENT, made and entered into this ___ day of __________, 20_____,
between Reliv’ International, Inc. (hereinafter the “Company”), and
____________________ (hereinafter “Employee”).

     

    WHEREAS, the Company has
employed Employee and continues to employ Employee as of this date;
and

     

    WHEREAS, the Company, as a
further incentive to Employee to devote his best efforts on behalf of the
Company and remain in the employ of the Company, desires to grant to Employee to
shares of the Company’s stock;

     

    NOW, THEREFORE, it is hereby
agreed:

     

    1. Grant. The Company
hereby grants to Employee, subject to the terms and conditions set forth herein
and in the Company’s 2009 Incentive Stock Plan (the “Plan”) which is
incorporated herein by reference, the right to purchase __________ shares (the
“Restricted Stock”) of Stock of the Company. Unless otherwise defined herein,
capitalized terms used in this Agreement that are defined in the Plan have the
meaning set forth in the Plan.

     

    2. Restricted Stock
Terms. The Restricted Stock is subject to the following terms and
conditions:

     

    2.1. Purchase
Price.  The purchase price for the Restricted Stock shall be
$_____ per share. Employee shall have no rights with respect to such Restricted
Stock unless Employee shall have accepted executed this Agreement and paid the
aggregate purchase price per share of the Restricted Stock within 60 days
following the date set forth above. Subject to the restrictions set forth in
this Agreement (including Sections 2.2, 2.3 and 2.5), upon complying with the
preceding sentence, Employee shall have all the rights of a shareholder with
respect to the Restricted Stock. Unless the Committee shall otherwise determine,
any certificate evidencing shares of the Restricted Stock shall remain in the
possession of the Company until such shares are vested as provided in Section
2.4 below.

     

    2.2. Transfer of Restricted
Stock.  The Restricted Stock may not be sold, assigned,
transferred, pledged or otherwise encumbered or disposed of except as
specifically provided herein.

     

    2.3. Repurchase or
Forfeiture. In the event of termination of employment by the Company and
its Affiliates for any reason (including death, Disability, Normal Retirement
and for Cause), the Company shall have the right, at the discretion of the
Committee, to repurchase at their purchase price from Employee or Employee’s
legal representative any shares of the Restricted Stock that have not then
vested, or to require forfeiture of such shares to the Company if the Restricted
Stock was acquired at no cost. No additional shares of Restricted Stock will
vest after termination of employment for any reason. The Company must exercise
such right of repurchase or forfeiture within 90 days following such termination
of employment.

     

    2.4. Vesting. The
Restricted Stock shall vest in accordance with the vesting schedule and
performance targets (each a “Performance Target”) set forth in Schedule A attached
hereto. Upon vesting, the restrictions on transfer set forth in Section 2.2 and
the Company’s right of repurchase or forfeiture set forth in Section 2.3 shall
lapse. Subject to Section 11 of the Plan, the Committee, in its discretion,
may accelerate the vesting of all or any portion of the Restricted Stock in the
circumstances set forth in the Plan.

    
      
         

      

      
         

        
          

        

      

      
         

      

    

     

    2.5. Dividends. [Dividends
on the Restricted Stock shall be paid to Employee without regard to whether the
Restricted Stock or any portion thereof shall have vested as provided in this
Agreement.] [OR]
[Dividends on the Restricted Stock shall be paid to Employee only with
respect to those shares of Restricted Stock that are vested as provided herein.
Employee hereby waives his or her right to receive any dividends declared and
paid by the Company with respect to any shares of Restricted Stock that have not
vested as provided in this Agreement.]

     

    2.6. Certificate; Book Entry
Form; Legend. The Company shall issue the shares of Restricted Stock
either (a) in certificate form or (ii) in book entry form, registered
in the name of Employee, with legends, or notations, as applicable, referring to
the terms, conditions, and restrictions applicable to such Restricted Stock. Any
certificate issued for Restricted Stock prior to vesting will be inscribed with
the following legend:

     

    “The
transferability of this certificate and the shares of stock represented hereby
are subject to the terms and conditions (including forfeiture) relating to
Restricted Stock contained in the Reliv’ International, Inc. 2009 Incentive
Stock Plan and an Agreement entered into between the registered owner and Reliv’
International, Inc. Copies of such Plan and Agreement are on file at the
principal office of Reliv’ International, Inc.”

     

    2.7. Lock-up Agreement.
Employee agrees that, if so requested by the Company or the underwriters
managing any underwritten offering of the Company’s securities, Employee will
not sell, make any short sale of, loan, grant any option for the purchase of, or
otherwise dispose of, any shares of the Restricted Stock, without the prior
written consent of the Company or such underwriters, as the case may be, for a
period of 180 days (or such lesser time period as the Company may
establish) from the effective date of any registration of securities of the
Company under the Securities Act of 1933, as amended.

     

    2.8. Adjustment Upon Certain
Financing or Changes in Capitalization. As provided in the Plan,
(a) the number of shares of Restricted Stock and the purchase price shall
be adjusted as the Committee shall determine to be appropriate in the event of a
stock dividend, stock split or similar change in capitalization affecting the
Stock and (b) in the event of any merger, consolidation, dissolution or
liquidation of the Company, the Committee in its sole discretion may make such
substitution or adjustment in the number of shares of Restricted Stock and the
purchase price as it may determine and as may be permitted by the terms of such
transaction, or accelerate, amend or terminate this Agreement and any unvested
Restricted Stock upon such terms and conditions as it shall provide (which, in
the case of the termination of the vested portion of the Restricted Stock, shall
require payment or other consideration that the Committee deems equitable in the
circumstances), subject, however, to the provisions of Section 13 of the
Plan.

     

    3. Tax
Matters.

     

    3.1. Section 83(b)
Election. Employee acknowledges that he or she may file an election
pursuant to Section 83(b) of the Code to be taxed currently on the Fair Market
Value of the shares of Restricted Stock (less any purchase price paid for the
shares), provided that such election must be filed with the Internal Revenue
Service no later than 30 days after the date of this Agreement. Employee will
seek the advice of his or her own tax advisors as to the advisability of making
such a Section 83(b) election, the potential consequences of making such an
election and the other tax consequences of the award made pursuant to this
Agreement under federal, state, and any other laws that may be applicable. The
Company and its affiliates and agents have not and are not providing any tax
advice to Employee.

    
      
         

      

      
        2

        
          

        

      

      
         

      

    

     

    3.2. Withholding. Employee
shall, no later than the date as of which the value of the Restricted Stock or
other amounts received under this Agreement first becomes includable in the
gross income of Employee for federal income tax purposes, pay to the Company, or
make arrangements satisfactory to the Committee regarding payment of any
federal, state, local and/or payroll taxes of any kind required by law to be
withheld with respect to such income. The Company and its Affiliates shall, to
the extent permitted by law, have the right to deduct any such taxes from any
payment of any kind otherwise due to the participant. Employee may elect, with
the consent of the Committee, to have such tax withholding obligation satisfied,
in whole or in part, by (a) authorizing the Company to withhold from shares
of Stock to be delivered to Employee pursuant to this Agreement a number of
shares with an aggregate Fair Market Value (as of the date the withholding is
effected) that would satisfy the minimum withholding amount due with respect to
such Award or (b) delivering to the Company a number of mature shares of
Stock with an aggregate Fair Market Value (as of the date the withholding is
effected) that would satisfy the minimum withholding amount due.

     

    4. Change of Control.
Upon the occurrence of a Change of Control as defined in Section 13 of the
Plan:

     

    4.1. Subject to the provisions
of Section 4.3 below, after the effective date of such Change of Control and
provided Employee has timely paid the purchase price as provided in 2.1,
Employee shall be entitled to receive, in lieu of shares of Stock (or
consideration based upon the Fair Market Value of Stock), shares of such stock
or other securities, cash or property (or consideration based upon shares of
such stock or other securities, cash or property) as the other holders of shares
of Stock received in connection with the Change of Control.

     

    4.2. The Committee may
accelerate, fully or in part, the time for vesting of, and waive any or all
conditions and restrictions on such vesting, the Restricted Stock) effective
upon a date prior or subsequent to the effective date of such Change of Control,
as specified by the Committee.

     

    4.3. This Agreement may be
cancelled by the Committee as of the effective date of any such Change of
Control provided that (a) prior written notice of such cancellation shall
be given to Employee and (b) Employee shall have the right to exercise his
or her rights under this Agreement and the Restricted Stock to the extent that
the same is then exercisable or, in full, if the Committee shall have
accelerated the time for exercise of such unexercised and unexpired Restricted
Stock during the 30 day period preceding the effective date of such Change
of Control.

     

    5. General.

     

    5.1. Shareholder Rights.
Employee has no rights as a shareholder of the Company unless and until the
Restricted Stock has been issued (or an appropriate book entry has been
made).

     

    5.2. Employment Rights.
The adoption of the Plan or the award of Restricted Stock do not confer upon
Employee any right to continued employment with the Company or any
Affiliate.

     

    5.3. Consent to Electronic
Delivery. Certain statutory materials relating to the Plan may be
delivered to Employee in electronic form. By accepting the Restricted Stock,
Employee consents to electronic delivery and acknowledge receipt of these
materials, including the Plan and the Plan prospectus.

    
      
         

      

      
        3

        
          

        

      

      
         

      

    

     

    5.4. Governing Law. The
Agreement shall be governed by and shall be construed according to the laws of
the State of Missouri.

     

    5.5. Entire Agreement. The
foregoing, together with and subject to all the terms and conditions of the
Plan, is the entire agreement between the Company and Employee with respect to
the Restricted Stock and may not be altered, modified, changed or discharged
except in a writing signed by a duly authorized officer or director of the
Company.

     

    IN WITNESS WHEREOF, the
parties have executed this Agreement as of the day and year first above
written.

     

    
      
        
          
            
              
                
                  
                    	 
      	
                            RELIV’
      INTERNATIONAL, INC.

                          
	 
      	 
      	 
      	 
      
	 
      	
                            By:

                          	 
      	 
      
	 
      	
                            Name:

                          	 
      	 
      
	 
      	
                            Title:

                          	 
      	 
      
	 
      	 
      	 
      	 
      
	 
      	
                            EMPLOYEE:

                          
	 
      	 
      	 
      	 
      
	 
      	 
      	 
      	 
      
	 
      	
                            Name:

                          	 
      	 
      

                  

                

              

            

          

        

      

    

    
      
         

      

      
        4Fourth
Amendment To Loan Agreement

     

    This
Fourth Amendment to Loan Agreement (“Amendment”) is dated as of November __,
2010, and is between Regions Bank, an Alabama banking corporation, as successor
by merger to Union Planters Bank, N.A. (“Lender”) and Bioanalytical Systems,
Inc., an Indiana corporation (“Borrower”).

     

    Recitals

     

    Lender,
Borrower and BAS Evansville, Inc. (“BAS”) entered into a certain Loan Agreement
dated October 29, 2002, as amended by a certain Amendment to Loan Agreement
dated June 1, 2004 and a certain First Amendment to Loan Agreement dated
February 11, 2008 (collectively, the “Prior Loan Agreement”) in connection with
(i) a certain Promissory Note (Term Loan) executed by Borrower in favor of
Lender in the original principal amount of $5,410,000.00 dated October 29, 2002,
as amended by Amendment to Promissory Note (Term Loan) dated June 1, 2004, (ii)
a certain Promissory Note (Loan (West Lafayette)) executed by Borrower in favor
of Lender in the original principal amount of $2,250,000.00 dated October 29,
2002, as amended by Amendment to Promissory Note (Loan (West Lafayette)) dated
June 1, 2004, and (iii) a certain First Replacement Promissory Note (Loan (Mt.
Vernon)) executed by Borrower and BAS in favor of Lender in the original
principal amount of $1,698,540.11 dated February 11, 2008 (“Mt. Vernon Note”)
(all notes listed in this recital are collectively, the “Prior
Notes”).  As security for the Prior Loan Agreement and the Prior
Notes, Borrower granted to Lender a certain Real Estate Mortgage and Security
Agreement (Fixture Filing) (West Lafayette) dated October 29, 2002, and recorded
on November 19, 2002, as Instrument No. 02037358 with the Office of the Recorder
of Tippecanoe County, Indiana, and BAS Evansville, Inc. granted to Lender a
certain Real Estate Mortgage and Security Agreement (Fixture Filing) (Mt.
Vernon) dated October 29, 2002, and recorded on November 13, 2002, as Instrument
No. 20027318 with the Office of the Recorder of Posey County, Indiana
(collectively, the “Prior Mortgages”).

     

    Lender
and Borrower entered into a certain Loan Agreement dated December 18, 2007, as
amended by a certain First Amendment to Loan Agreement dated January 3, 2008, a
certain Second Amendment to Loan Agreement dated May 18, 2009 and a certain
Third Amendment to Loan Agreement dated January 13, 2010 (as may be further
amended from time to time, collectively, the “Loan Agreement”).

     

    To
further secure the Indebtedness of Borrower to Lender, BAS executed and
delivered to Lender a certain Unconditional Unlimited Continuing Guaranty dated
January 13, 2010 whereby BAS guarantied the Indebtedness of Borrower to Lender
including, but not limited to, the Prior Notes and the Replacement Note (as such
term is hereinafter defined).

     

    The
parties desire to amend the Loan Agreement to modify certain covenants provided
by the Loan Agreement, as herein provided.

     

    Terms

     

    NOW,
THEREFORE, in consideration of the foregoing and the mutual obligations of the
parties hereto, the Loan Agreement is hereby amended as
follows:

    
      
         

      

      
         

        
          

        

      

      
         

      

    

    
      	
               
      

            	
              1.

            	
              Amendments to the Loan
      Agreement.

            

    

     

    A.         Section 1 (Definitions) is
amended to add the following definition:

     

    “Capital Expenditures” means
all expenditures which, in accordance with  generally accepted
accounting principles, would be required to be capitalized and shown on the
balance sheet of Borrower, including expenditures in respect of capital leases,
but excluding expenditures made in connection with the replacement, substitution
or restoration of assets to the extent financed (a) from insurance proceeds (or
other similar recoveries) paid on account of the loss of or damage to the assets
being replaced or restored or (b) with awards of compensation arising from the
taking by eminent domain or condemnation of the assets being
replaced.

     

    B.          Section 7 (Borrower’s Affirmative
Covenants).  Section 7 (Borrower’s Affirmative Covenants) of
the Loan Agreement is hereby amended by deleting the existing subsection (d) and
replacing it with the following subsection (d):

     

    d.           Liens.  Borrower
will cause any lien (including, without limitation, any judgment, attachment,
execution, mechanic’s lien, or federal or state income tax lien) that may attach
to Borrower’s real estate or personal property to be satisfied and released no
later than thirty (30) days after attachment, except for (i) the lien of current
property taxes and assessments, (ii) liens contested in good faith in an
appropriate proceeding if Borrower has given Lender any assurances Lender deems
necessary under the circumstances, (iii) liens in favor of Lender, (iv) any lien
in favor of Entrepreneur Growth Capital, LLC, or its successor as provider of an
asset-based line of credit, (the “Asset Based Lender”) to secure indebtedness
not to exceed the principal amount of $3,000,000.00, provided that any real
property lien is governed by an Intercreditor Agreement by and between Lender
and the Asset Based Lender, and (v) those liens permitted pursuant to Section
9(e) herein.

     

    C.          Section 8 (Borrower’s Financial
Covenants).  Section 8 (Borrower’s Financial Covenants) of the
Loan Agreement is hereby amended by deleting the existing subsections (b) and
(c) and replacing them with the following subsections (b) and (c):

     

    b.       Fixed Charge Coverage
Ratio.  Borrower will maintain a Fixed Charge Coverage Ratio of
not less than 1.25 to 1.00.  “Fixed Charge Coverage Ratio” means the
ratio of (i) the sum of Borrower’s aggregate net income for the current fiscal
year as of the end of such period, plus depreciation expense and other non cash
expenditures, plus interest expense, plus income tax expense, less Capital
Expenditures not funded with long term debt, less income tax paid or accrued in
the current fiscal year as of the end of such period, to (ii) the sum of all
interest payments and the principal payments on long-term debt paid or accrued
in the current fiscal year as of the end of such period, including payments made
under capitalized leases but excluding the anticipated principal reductions of
the Replacement Note and the Mt. Vernon Note on or before December 18, 2010 and
February 11, 2011, respectively.  The Fixed Charge Coverage Ratio will
be tested on a fiscal year-to-date basis at the end of each fiscal quarter
beginning December 31, 2010.

    
      
         

      

      
        -2-

        
          

        

      

      
         

      

    

    c.           Borrower
will maintain a Total Liabilities to Tangible Net Worth Ratio of not less than
2.10 to 1.00, tested quarterly at the end of each fiscal quarter beginning
December 31, 2010.

     

    C.          Section 9 (Negative
Covenants).  Section 9 (Negative Covenants) of the Loan
Agreement is hereby amended by deleting the existing subsections (d) and (e) and
replacing them with the following subsections (d) and (e):

     

    d.           Borrowing.  Borrower
will not, without Lender’s prior written consent, create, incur, assume or
suffer to exist any indebtedness except (a) trade accounts and normal business
accruals payable in the ordinary course of business, (b) Indebtedness to Lender,
(c) an asset-based line of credit available to Borrower from the Asset Based
Lender in the maximum principal amount not to exceed $3,000,000.00, (d)
indebtedness for Capital Expenditures, and (e) any other unsecured indebtedness,
nor shall Borrower assume, guarantee or otherwise become liable as a guarantor
or surety for the obligations of any person or firm except guaranties in favor
of Lender.

     

    e.           Liens and
Encumbrances.  Borrower will not, without Lender’s prior
written consent, create or permit to exist any mortgage, pledge, lien, security
interest or other encumbrance (except those in favor of Lender, except those in
favor of Asset Based Lender as permitted in Section 7.d. herein, and except
those encumbering the specific asset hereafter acquired in connection with any
Capital Expenditures) in any of Borrower’s tangible or intangible real or
personal property, whether now owned or hereafter acquired, nor will Borrower
become security on a recognizance or other bond.

     

    2.           Continuing
Effect.  All other terms, conditions, representations,
warranties and covenants contained in the Loan Agreement shall remain the same
and shall continue in full force and effect.  In consideration hereof,
Borrower represents and warrants that each representation and warranty set forth
in the Loan Agreement, as hereby amended, remains true and correct as of the
date hereof, except to the extent that such representation and warranty is
expressly intended to apply solely to an earlier date, that there presently
exist no known offsets, counterclaims or defenses to the performance of the
obligations under the Instruments (collectively, the “Obligations”) (such known
offsets, counterclaims or defenses, if any, being hereby expressly waived), and
that Borrower has no other known claims, demands, allegations or rights of
action of any nature based on any matter arising from or related to the
Obligations or Borrower’s relationship with the Lender (such known claims,
demands, allegations or rights of action, if any, being hereby expressly waived)
nor has there occurred any Event of Default under the Loan Agreement or any of
the Instruments, and that there will be no Event of Default after giving effect
to the transactions contemplated by this Amendment.  The
representations and warranties contained in the Loan Agreement originally shall
survive this Amendment in their original form and shall survive as continuing
representations and warranties of Borrower.  Except as expressly
herein provided, the Loan Agreement and this Amendment shall be interpreted,
wherever possible, in a manner consistent with one another, but in the event of
any irreconcilable inconsistency, this Amendment shall control.  The
parties each hereby agree to cooperate in all reasonable requests of each other
party hereto, including, without limitation, the authentication of financing
statements and other documents, which the requesting party deems reasonable,
necessary, appropriate or expedient to carry out the intents and purposes of
this Amendment.  Capitalized terms used herein and not specifically
herein defined shall have the meanings ascribed in the Loan
Agreement.

    
      
         

      

      
        -3-

        
          

        

      

      
         

      

    

    It was Lender’s intent that the Loan
Agreement should replace the Prior Loan Agreement and, in good faith, Lender has
been monitoring and administering the Obligations and the Prior Notes with the
covenants contained in the Loan Agreement.  By execution of this
Amendment, Borrower and Lender agree that (i) the Prior Loan Agreement, (ii) the
Prior Notes, (iii) the Prior Mortgages, (iv) a certain First Replacement
Promissory Note (Term Loan) executed by Borrower in favor of Lender in the
original principal amount of $1,400,000.00 dated January 3, 2008 (the
“Replacement Note”), (v) a certain Real Estate Mortgage and Security Agreement
(Fixture Filing) granted by Borrower to Lender dated December 18, 2007, and
recorded January 10, 2008, as Instrument No. 200808000629 with the Office of the
Recorder of Tippecanoe County, Indiana, and (vi) a certain Real Estate Mortgage
and Security Agreement (Fixture Filing) granted by Borrower to Lender dated
December 18, 2007, and recorded February 19, 2008, as Instrument No. 200800695
with the office of the Recorder of Posey County, Indiana, and all documents and
instruments executed in connection therewith, shall be monitored and
administered in accordance with the Loan Agreement, and in the event of any
irreconcilable inconsistency between the Prior Loan Agreement and the Loan
Agreement, the Loan Agreement shall control.

     

    3.           Conditions
Precedent.  Notwithstanding anything contained in this
Amendment to the contrary, the Lender shall have no obligation under this
Amendment until each of the following conditions precedent have been fulfilled
to the satisfaction of the Lender:

     

    (a)          The
Lender shall have received each of the following, in form and substance
satisfactory to the Lender:

     

    (1)          This
Amendment and such other instruments, documents and opinions as the Lender shall
reasonably require, all duly executed by the parties thereto in the forms
approved by the Lender;

     

    (2)          A
Consent and Confirmation of Guaranty executed by BAS;

     

    (3)          A
duly executed certificate of an authorized officer of Borrower (A) certifying as
to attached copies of resolutions of the Board of Directors of Borrower
authorizing the execution, delivery and performance of this Amendment, the Loan
Agreement, the Instruments, as amended, and any other documents provided for in
this Amendment to which Borrower is a party or certifying that prior resolutions
executed and delivered to the Lender are in full force and effect, and (B)
certifying as complete and correct as to attached copies of the Articles of
Incorporation and Bylaws of Borrower or certifying that such Articles of
Incorporation and Bylaws have not been amended (except as shown) since the
previous delivery thereof to the Lender;

    
      
         

      

      
        -4-

        
          

        

      

      
         

      

    

    (4)          A
duly executed certificate of an authorized officer of BAS (A) certifying as to
attached copies of resolutions of the Board of Directors of BAS authorizing the
execution, delivery and performance of the Consent and Confirmation of Guaranty
or certifying that prior resolutions executed and delivered to the Lender are in
full force and effect, and (B) certifying as complete and correct as to attached
copies of the Articles of Incorporation and Bylaws of Borrower or certifying
that such Articles of Incorporation and Bylaws have not been amended (except as
shown) since the previous delivery thereof to the Lender;

     

    (5)          Payment
of a modification fee in the amount of $25,000.00, which fee the Borrower
acknowledges was earned upon execution of this Amendment and is due and payable
and non-refundable;

     

    (6)          All
reasonable expenses of the Lender (including, without limitation, reasonable
attorneys’ fees), shall have been reimbursed by Borrower.

     

    (b)          All
legal matters incident to this Amendment shall be reasonably satisfactory to the
Lender and its counsel.

     

    4.           Counterparts.  This
Amendment may be executed in one or more counterparts, each of which shall be
deemed an original but all of which together will constitute one and the same
instrument.  Facsimile signatures will be deemed acceptable and
binding.

     

    The parties are signing this Amendment
on the date stated in the introductory paragraph.

     

    LENDER:

    
      
        	 
      	
                REGIONS
      BANK

              
	 
      	 
      	 
      
	 
      	
                By: 

              	
                  

              
	 
      	 
      	
                Michael
      F. Zingraf, Senior Vice
President

              

      

    

    
      
         

      

      
        -5-

        
          

        

      

      
         

      

    

    

    BORROWER:

    
      
        	 
      	
                BIOANALYTICAL
      SYSTEMS, INC.

              
	 
      	 
      	 
      
	 
      	
                By: 

              	
                  

              
	 
      	 
      	
                Michael
      R. Cox, Vice President –
Finance

              

      

    

    

    
      
        	
                STATE
      OF INDIANA

              	
                )

              	 
      
	 
      	
                )

              	
                SS:

              
	
                TIPPECANOE
      COUNTY

              	
                )

              	 
      

      

    

    

    Before me, the undersigned Notary
Public, personally appeared Michael R. Cox, the Vice President of Finance of
Bioanalytical Systems, Inc., an Indiana corporation, who on behalf of said
entity acknowledged the execution of the foregoing instrument and swore to the
truth of the statements made therein.

    

    Witness my hand and Notarial Seal this
_____ day of November, 2010.

    

    SEAL

    
      
        	 
      	
                  

              
	 
      	
                Notary
      Public Signature

              
	 
      	 
      
	 
      	
                  

              
	 
      	
                Printed
      Name

              

      

    

    

    
      
        
          
            	
                    My Commission Expires: 

                  	
                      

                  
	 
      	 
      
	
                    County
      of Residence:

                  	
                      

                  

          

        

      

    

    
      
         

      

      
        -6-

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