Financial Responsibility

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Financial responsibility.
State of _________
ss
County of _________
_________ being duly sworn, says that he [she] is a resident and freeholder within the county of _________
state of _________ and is worth _________ dollars, exclusive of property exempt from execution, and over and
above the amount of all his [her] debts and liabilities, and that his [her] property consists of the premises known as
_________ the title to which is of record in the deponent's name in the office of _________ of the county of
_________ state of _________; and that the same is of the value of not less than _________ dollars, and is subject
to no incumbrances except _________.
Sworn to, etc.

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