On this the day of , 19 , before me, , the undersigned officer, personally appeared , known to me (or satisfactorily proven) to be serving in or with the armed forces of the United States and to be the person whose name is subscribed to the within instrument acknowledged that he executed the same for the purposes therein contained. And the undersigned does further certify that he is at the date of this certificate a commissioned officer of the rank stated below and is in the active service of the armed forces of the United States.
Signature of Officer.Rank of Officer and CommandTo which attached