Date: 

I (we)

hereby authorize Rabbi Tzali Wilschanski to dispose of all the Chometz that may be in my (our) possession wherever it may be-at home, at my (our) place of business, or elsewhere-in accordance with the requirements of Jewish law as incorporated in the special contract for the sale of Chometz.

Home Address

Street Apt. #

CityState Zip

Tel. #

Business Address

StreetSuite #_

CityStateZip

Tel. #

Signature

Spouses Signature