STATE OF ____________
COUNTY OF ____________
THE UNDERSIGNED, being first duly sworn, deposes and says:
1. __________ is the sole owner of that business known as ___________, located and
doing business in the State of , whose address is _______________.
2. __________ has the full right and authority to enter into and consummate the sale of
said business, including its goodwill, trade or fictitious name, stock in trade, fixtures,
furniture, office equipment, supplies, licenses, telephone rights including the right to
all existing telephone numbers servicing said business, and those items of equipment
specifically listed and described in Schedule "A", including the business and fictitious
3. __________ is the owner of the personal property, inventory, and equipment being
sold in fee simple, unencumbered by any liabilities, debts, or liens, be they state,
federal or private, except as more fully set out in Schedule "B" attached hereto, if any.
4. There are no other federal, state or local taxes owed of any kind, type or description
for the operation of the business known as ___________, prior to and including the
date hereof, including, but not limited to, sales tax, social security and income tax,
and any payroll taxes. Any assessments, fees, or taxes which have yet to become due
will be paid immediately at such time as they are calculated, made or assessed.
Affiant's failure to pay said obligations shall entitle the BUYER to a right of SET-
OFF and INDEMNIFICATION, a right which may appear in the Purchase Contract
and Security Agreement and may be placed in the Promissory Note executed
5. Any and all representations set out in the contract are true as of the date hereof.
6. Other than as set out in Schedule "B", there are no debts or obligations of any kind
encumbering the inventory and assets being sold and there are no outstanding security
interests or liens in said inventory or assets.