Loan Purpose, Affidavit

The undersigned being first duly sworn on oath deposes and states:

That the proceeds of the loan of $______ (________________ &___/100 dollars), being furnished us this __________day of ______________, 20____, from ______________________________
______________________________
______________________________

Will be used for:
______________________________and for no other purpose.

Subscribed and sworn to this _____ day of ________, 20__ under pains and penalties of perjury.

_______________________________
Notary
My Commission Expires on: