STATE OF___________________)
                                                   ) SS:
COUNTY OF _________________)

_________________________________________, BEING DULY SWORN, DEPOSES AND SAYS:

I AM A REAL ESTATE BROKER LICENSED BY THE STATE OF NEW YORK. MY REAL ESTATE

                    LICENSE NUMBER IS:_____________________________________________

                   MY ADDRESS IS:_________________________________________________

THE NAME OF THE SELLER OR PERSON RESPONSIBLE FOR THE REAL ESTATE BROKERAGE

THE NAME OF THE PERSON AUTHORIZING THE SALE ON BEHALF OF THE SELLER WAS
THE SELLER HIMSELF. THE DATE OF THE AUTHORIZATION WAS:_____________________

A COPY OF THE WRITTEN AGREEMENT IS ANNEXED HERETO AS EXHIBIT A.

THE REAL PROPERTY INVOLVED WITH THIS TRANSACTION IS: (PROPERTY DESCRIPTION):  

THE AMOUNT OF THE COMMISSION CLAIMED IS:

THE BROKERAGE SERVICE PERFORMED CONSISTED OF THE PROCURING OF A PURCHASER BY

THE PURCHASER WAS PROCURED ON


__________________________________________________________________________________ 

SWORN TO BEFORE ME THIS ________________DAY OF ______________________, 19____. 

___________________________________________
NOTARY

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