_________ of the city of _________ county of _________ and state of _________ being duly sworn, deposes and says, that he [she] is the owner of the fruit and vegetable store located at No. _________ _________ street in the city of _________ and that there are no outstanding debts and that all his [her] bills have been paid and that he [she] makes this affidavit for the purpose of inducing _________ to purchase the store.

[Signature]

Subscribed and sworn to, etc.