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State of __________________________ County of _______________________

____________________________, of lawful age, being first duly sworn, on oath states:


That he is the Seller in that certain contract for the sale of assets dated ___________,
20__ between himself, as Seller, and ___________________ as Buyer;

That this Affidavit is made pursuant to the terms and provisions of the Uniform
Commercial Code and is furnished to the above named Buyer in connection with the sale
and transfer described and referred to in the above mentioned contract;

That the following is a true, complete and accurate list of all of the creditors of affiant
and of all persons who, to the knowledge of affiant, assert or have claimed to assert one
or more claims against affiant, together with the correct business addresses of each such
creditor or claimant and the amounts due and owing to such creditors and claimants, to

Name of Business Amount Admitted or

Creditor Address Of Claim Disputed

1._____________________ ___________________ ___________ ____________

2._____________________ ___________________ ___________ ____________

3._____________________ ___________________ ___________ ____________


SUBSCRIBED and sworn to before me this _______ day of ______________, 20__.

_________________________ _____________________________
Notary Public [Notarial Seal]

My commission expires: