1. He or she is the authorized agent in this behalf of _________ of _________.

2. The above-named _________, is justly indebted to the above-named claimant on certain notes signed by _________, payable to order of claimant, aggregating in principal amount $_____, the notes are numbered _________ to _________ both inclusive, and due _________, and monthly thereafter, to and including _________, each for the sum of $_____, bearing interest at _________ percent per year from _________, to maturity of each note, and at _________ percent per year after maturity.

3. Indebtedness arose on account of purchase and installation of a _________ in a certain building owned by _________.

4. An itemized statement of indebtedness is attached here and made a part of this claim.

5. No part of debt has been paid.

6. There are no set-offs or counterclaims to debt nor has judgment been rendered on it.

7. Claimant is a secured creditor by reason of conditional sales contract dated _________, between _________ and claimant, covering installation of _________ in building, copy of which conditional sales contract is attached here and made a part of this claim.