Before me __________personally appeared ________(transferor or agent) who, being by me first duly sworn upon his oath, deposed and said that the foregoing statement contains the names of all the creditors of _______(name of transferor), together with their addresses, and that the amount set opposite each of their respective names is the amount now due and owing and which shall become due and owing by _________(transferor) to such creditors, and that there are not creditors holding claims due or which shall become due for or on account of goods, wares, merchandise, or fixtures, or equipment used or to be used in the display, manufacture, care, or delivery of any goods, wares, or merchandise, including movable store and office fixtures, vehicles, or other goods and chattels of the transferor's business purchased upon credit or on account of money borrowed to carry on the business of which the property is a part other than as set forth in said statement, and that the facts set out in this affidavit are within the personal knowledge of the affiant.
_____________________________
Sworn and subscribed to before me
this ___________day of_______, 19___.
_____________________________
Title of officer taking oath
La. R.S. § 9:2961