“State of Arkansas, County of . . . . . . . . . . . . .
其 . . . . . . . . . . . . . ., being duly sworn, deposes and says that at least . . . . . . . . . . . . . . dollars worth of work or improvements were performed or made upon . . . . . . . . . . . . . . (here describe claim) situated in . . . . . . . . . . . . . . Mining District, County of . . . . . . and State of Arkansas, between the . . . . . . day of . . . . . . and the . . . . . . day of . . . . . . A. D., and that such expenditure was made by or at the expense of . . . . . . . . . . . . . ., owners of said claim, for the purpose of complying with the law for holding the claim
(Signature) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Jurat) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ”
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