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I hereby acknowledge the loss of the original Green Woods Club, Inc., Certificate No. __________ and waive all future claims and rights of membership in the Green Woods Club.

Certificate No. __________ is void, said certificate having been issued to me and subsequently lost or destroyed.

I hereby approve the following amounts as being true and correct and agree to the amount that will be refunded to me on receipt of this waiver and bond resale by the Green Woods Club.

Certificate Purchase Price In (year):_______ for an amount of $_______

Signature: _________________________________   Date: _____________________

Print Name: ________________________________