THE GRANTOR, _______________________________, City of___________________, County

 of_____________, State of _________ for the consideration of________________________Dollars

 ($______________) CONVEY and QUITCLAIM to_________________________________

of___________________________________City of_____________________County of ______________

 State of ____________, all interest in the following described real estate situated in the County of

Portage, in the State of Ohio, to wit: See Exhibit A attached.

Dated this ____________day of (mo.) ________________, (yr.) ____________.

Grantor’s Signature___________________________________________________

______________________________________________________________________________________

STATE OF OHIO, COUNTY OF PORTAGE

I, _____________________________________, Notary Public in and for the state of Ohio, do hereby certify

 that on this_________day of (mo.) ____________________, (yr.) ___________________,

 ________________________ personally appeared before me (or proved to me on the basis of satisfactory evidence) to be the individual described in and who executed the within instrument and acknowledged that he signed the same as his free and voluntary act and deed for the uses and purposes herein mentioned.

Given under my hand and official seal this ____________day of (mo.)______________________, (yr.) _________________.

My commission expires (mo./day) _______________________________, (yr.) __________________.

___________________________________________
Notary Public