STATE OF RHODE ISLAND AND PROVIDENCE PLANTATIONS

________________________, SC. ____________________DIVISION

_______________________________________

Plaintiff

vs. C.A. No._____________

_______________________________________

Defendant

The undersigned, being duly sworn, upon oath deposes and says that the ______________________ was not at the time of this commencement of said action, nor is now in the Military Service of the United States as defined in Article 1 of the "Soldiers and Sailors" Civil Relief Act of 1940", as amended.

___________________________

State of Rhode Island

___________________, Sc.

Sworn and subcribed to before me at ______________________ on this _____

day of _________________, A.D. 20__.

___________________________

Notary Public