“On this . . . . . . . . . . . . . . day of . . . . . . . . . . . . . . , 19 . . . . . ., before me, . . . . . . . . . . . . . ., the undersigned officer, personally appeared . . . . . . . . . . . . . . . . . . . . . . . . . . . . (Serial No. . . . . . . . . . . . . . .) known to me or satisfactorily proven to be (serving in or with the armed forces of the United States) (a dependent of . . . . . . . . . . . . . . . . . . . . . . . . . . . ., (Serial No

. . . . . . . . . . . . . .) a person serving in or with the armed forces of the United States) and to be the person whose name is subscribed to the within instrument and 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

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Signature of the Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Rank and Serial No. of Officer and Command to which attached.”