The following certificate shall be printed on the plat and signed by the owner or owners. The certificate as shown in this section may be amended if circumstances of ownership warrant. Any signatures appearing on the certificate shall be notarized by a notary public for the state.

CERTIFICATE OF OWNERSHIP AND DEDICATION

I (we) hereby certify that I am (we are) the owner(s) of the property shown and described hereon and that I (we) hereby adopt this plan of subdivision with my (our) free consent, and dedicate all streets, alleys, walks, parks and other open spaces to public or private use as noted.

(date) ___________ 20___

Witnessed by:

______________    ______________
Witness     Owner

_____________    ______________
Witness    Owner
Notary Acknowledgment: