I reside at _________ and am the owner in fee simple of the following described premises: _________.

The premises have been in my possession since [Date] that my possession has been peaceable and undisturbed, and the title has never been disputed, questioned, or rejected, nor insurance refused, as far as I know. I know of no facts by reason of which the possession or title might be called in question, or by reason of which any claim to any part of the premises or any interest in it adverse to me might be set up. There are no judgments against me unpaid or unsatisfied of record entered in any court of this state, or of the United States, and the premises are, as far as I know, free from all leases, mortgages, taxes, assessments, charges and other liens and encumbrances, except _________.

The premises are now occupied by _________.

No proceedings in bankruptcy have ever been initiated by, or against me in any court or before any officer of any state, or of the United States, nor have I at any time made an assignment for the benefit of creditors, nor an assignment, now in effect, of the rents of the premises or any part of it.

I am a citizen of the United States, and am more than _________ years old. I am by occupation _________.

I am married to _________, who is over _________ years of age and is competent to convey or mortgage real estate. I was married to _________ on _________(date). I have never been married to any other person now living. I have not been known by any other name during the past _________ years.

There are no actions pending affecting the described premises. No repairs, alterations, or improvements have been made to the premises which have not been completed more than _________ days prior to the date of this affidavit. There are no facts known to me relating to the title to the premises which have not been set forth in this affidavit.

This affidavit is made to induce _________ to make a loan to me in the amount of $_____, to be secured by a mortgage on the premises.

Sworn and subscribed before me [Date].