) s.s.:

SHIRE OF -------------)

1. Introduction. [name], being duly sworn, deposes and says:

2. Description of Deponent. I reside at [address] and am the person who executed the attached bill of sale.

3. Description of Property--Statement of Ownership. I am the sole owner of the goods and chattels described in the bill of sale and have full right and power to sell and transfer them.

4. No Mortgages or Liens. There are no mortgages, liens, security interests, or other encumbrances affecting the goods and chattels except [list of encumbrances].

5. Debts. I have no debts that affect the goods and chattels except [list of debts].

6. No Suits, Judgments, or Bankruptcy or Insolvency Proceedings. No actions or proceedings in which I am a defendant or respondent or which would affect the goods and chattels are pending in any court or other forum. There are no judgments, executions, attachments, or replevins outstanding against me. I have filed no petition in bankruptcy or for an arrangement with creditors nor has any such petition been filed against me in the past [number] years. I have not taken advantage of any law relating to insolvency in the past [number] years.

7. Inducement to Buyer. I make this affidavit for the sole purpose of inducing [name] to purchase the goods and chattels described in the annexed bill of sale [omitted], knowing full well that [name] will rely upon the representations made herein.

Sworn to before me [signature]

[dated] Deponent

[signature]

Justice of Peace