State of..........................

County of................................

the Mortgagor.. in the foregoing Mortgage, named, and..................

...................................................... the Mortgagee...

in said Mortgage named, each being duly sworn, each for himself, doth depose and say: that the aforesaid Mortgage is made in good faith and without any design to hinder, delay, or defraud any creditor or creditors.

Subscribed and sworn to before me, this ......... day of..........

189..., at the.........County of............