Affidavit Verifying Account. State of _________, _________ County. _________ personally appeared before me, and after being duly sworn says that (he or she) is _________; that the annexed account is a just and lawful claim against _________ of _________; that there is now due and owing from _________ the sum of _________ dollars, with interest from the _________ day of _________, _________[date], for goods and merchandise sold and delivered to _________[or as the case may be] at (his or her) special instance and request; that there are no credits, set-offs or counterclaims against it, either in law or equity; that _________ have no security whatever for any portion of the indebtedness; and that there is no usury present. [Signature of affiant] Subscribed and sworn to before me this _________ day of _________, _________[date]. In witness of which, I set my hand and seal at my office in the city of _________, county and state previously mentioned. [Signature, title of officer, and seal]