_________ being duly sworn, says that he [she] is a resident and freeholder within the county of _________ state of _________ and is worth _________ dollars, exclusive of property exempt from execution, and over and above the amount of all his [her] debts and liabilities, and that his [her] property consists of the premises known as _________ the title to which is of record in the deponent's name in the office of _________ of the county of _________ state of _________; and that the same is of the value of not less than _________ dollars, and is subject to no incumbrances except _________.

Sworn to, etc.