STATE OF XXSTATE
COUNTY OF XXCOUNTY
KNOW ALL YE MEN BY THESE PRESENTS,
That on this XXth day of XXmonth, XXyear, personally came
and appeared before me XXyourname, of
XXstreet, XXcity, XXstate XX00000-0000,
known, and known to me, who after being first duly sworn, deposes and says:
I present XXevidence. . .
XXend evidence above the following line.
FURTHER AFFIANT SAYETH NOT.
SUBSCRIBED TO AND SWORN TO before me this XXth day
of XXmonth, XXyear.
My Commission Expires ________________