State of _______________________)
County of ______________________)
We (I) _________________________________________ (wife) husband), being first duly sworn, depose and say (deposes and says) that we are (I am) occupying all (a part) of the land (proposed to be) acquired by the United States of America from _______________________ described as ___________ hectares (acres), Tract No._____ lying in _________________ County, State of _________________ and hereby aver that we are (I am) occupying said land as the tenants (tenant) of _________________________________ that we (I) claim no right, title, lien or interest in and to the above-described premises or any part thereof by reason of said tenancy or otherwise and will vacate said premises upon demand for the possession of said land by the United States of America.
Dated this ___________ day of ___________, 19__.
This form should be completed before a Notary Public if it is intended to be recorded, otherwise the form should show it was signed in the presence of two witnesses.