Affidavit by examville

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									                                          AFFIDAVIT


        STATE OF ________(1)_______)

                        SS:

        COUNTY OF ______(2)________)

        KNOW ALL YE MEN BY THESE PRESENTS,

       That on this _(3)__ day of ______(4)_________, 19_(5)_, personally came and
appeared before me ______(6)__________, of __________(7)_______________, known, and
known to me, who after being first duly sworn, deposes and says:

(Insert Sworn Statement)

        FURTHER AFFIANT SAYETH NOT.

                        __________(8)____________
								
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