VERIFIED STATEMENT:
PHILIPPINE ISLANDS
PROVINCE OR CITY OF _}
Before me, the undersigned authority, personally appeared __ (vendor, mortgagor, agent or representative, as the case may be), bearing cedula No. __ issued at ___ on the day of _ who, by me being first duly sworn, upon his oath, deposes and states that the foregoing statement contains the names of all of the creditors of __ (vendor, or mortgagor) together with their addresses, and that the amount set opposite each of said respective names, is the amount now due and owing, and which shall become due and owing by _ (vendor or mortgagor) to such creditors, and that there are no creditors holding claims due or which shall become due, for or on account of goods, wares, merchandise, provisions or materials purchased upon credit or on account of money borrowed, to carry on the business of which said goods, wares, merchandise, provisions or materials are a part, other than as set forth in said statement.
Subscribed and sworn to before me this ___ day of __, 19_, at __