Date policy issued: ___________________
Date policy expires: __________________


SWORN STATEMENT IN PROOF OF LOSS

To the ___________________________________.
At time of loss, by the above indicated policy of insurance you
insured:
_____________________________________________________________
against loss by __________________________, upon the property 
described by the under Schedule "A," according to the terms and 
conditions of the same policy and all forms, endorsements, 
transfers and assignments attached thereto.

Time and origin: A ____ loss occured about the hour of ____ __m., 
on the _______.  The cause and origin of said loss were:
_______________________________________________________________

Occupancy: The building described or containing the property 
described, was occupied at the time of the loss as follows, and 
for no other purpose whatever:
_____________________________________________________________
Title and Interest: At the time of the loss the interest of your 
insured in the property described therein was _________.  
Changes. Since the said policy was issued there has been no 
assignment thereof, or change of interest, use, occupancy, 
location or exposure of the property described, except: ______.
Total insurance. The total amount of insurance upon the property 
described by this policy was, at the time of the loss, $ 
____________ ( ____________&___/100 Dollars) as more particularly 
specified in the apportionment attached under Schedule "C," 
besides which there was no policy or other contact of insurance, 
written or oral, valid or invalid.
The actual cash value of said property at the time of the loss 
was $ ____________ ( ____________&___/100 Dollars).
The Whole Loss and Damage was $ ____________ ( ___________ & 
___/100 Dollars)
The amount claimed under the above numbered policy is $ 
______________ ( ____________&___/100 Dollars)
The said loss did not originate by any act, design or procurement 
on the part of your insured, or this affiant; nothing has been 
done by or with the privity or consent of your insured or this 
affiant, to violate the conditions of the policy, or render it 
void; no articles are mentioned herein or in annexed schedules but 
such as were destroyed or damaged at the time of said loss; no 
property saved has in any manner been concealed, and no attempt to 
deceive the said company as to the extent of said loss, has in any 
manner been made. Any other information that may be required will 
be furnished and considered a part of this proof.
The furnishing of this blank or the preparation of proofs by a 
representative of the above insurance company is not a waiver of 
any of its rights.

                           
State of ___________
County of __________

Subscribed and sworn to before me this ______ day of __________ 
19______.


_____________________________________________