STATE OF ____________________
COUNTY OF ____________________

I, ____________________, being duly sworn, do hereby depose and attest that:
1. I own the property at ____________________
2. The property is legally described as follows: ____________________
3. No other person has any claims, through written or unwritten agreements, on the aforementioned property.
4. There are no other tenants living on the premises.
5. The property is offered to potential buyers without lien. I have no outstanding debts, claims, leases, mortgages, security interests, contracts, taxes, assessments or conveyances that would result in a claim of lien on the property.
____________________
AFFIANT
Subscribed and sworn to before me this ____________________ day of ____________________ 20 ____________________

____________________
(Notary Public),

____________________ County.

My commission expires ____________________ 20 ____________________