I, (____), petitioner (or complainant, plaintiff, appellant or whatever party he may be) in this matter, do hereby swear (or affirm) that I have neither received, nor conspired to receive, any valuable consideration or assistance whatever as an inducement to the commencement or further prosecution of the proceedings in this matter.
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(Signature of Affiant)
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Affiant
Sworn to and subscribed before me on this, the (____) day of (____), 2(____).
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(Signature of Official)
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(Title of Official)