RETIREMENT STATUS AFFIDAVIT STATE OF LOUISIANA PARISH OF BEFORE ME, the undersigned personally came and appeared, (Name of Affiant) who, after being sworn, did depose and said that he/she reached the age of seventy (70) years on , that he/she wishes to retire his/her notary commission, and certifies that he/she will no longer exercise the duties and functions of a notary. Signature of Affiant Sworn to and subscribed, before me this day of , . Signature of Notary Public Printed Name and ID# of Notary Public American LegalNet, Inc. www.USCourtForms.com