I, the undersigned, _________, of the city of _________, county of _________, state of _________, state that _________, my wife, paid to me $_____ as follows: $_____ paid to and received by me as proceeds of the sale of _________. The $_____ having been paid by my wife, or for her account, to me upon the agreement between us that I should hold money and invest the same in another homestead for her and for her own separate use, and that whenever I should take title to any premises so to be purchased and improved out of or from the money, it should and would be, and would be and become and belong, to her, for her own separate use, her heirs and assigns forever, and if such title should be taken in my name I would hold the same in trust for her.

And I state that I invested $_____ so received by me from my wife, in and took title to the premises known as _________, in my individual name. And I further state that I now hold the title and the improvements on it in my individual name, solely and only as trustee, for the sole use and benefit of my wife, _________, her heirs and assigns forever and not otherwise.