List of creditors. Following is a true, correct and full list of the names and business addresses of all known creditors of, and claimants against, _________ doing business [under the name of _________] at _________ Street in the City of _________, in the State of _________, whose claims now are owing or are to become owing, or are asserted or are to become asserted; and the amount, if known, of the debt to, or claim by, each is set opposite h— name and business address, and there are no other known debts of, or claims against, _________. Name Business Address Amount
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[Signature of seller or his agent] State of _________ ss County of _________
_________, being first duly sworn, on oath deposes and states that —he is the person who signed the foregoing statement and list of creditors, that —he understands its contents, and that the same is true and complete. Subscribed and sworn to before me on _________[date]. _________, Notary Public [Seal] My commission expires _________.