United States Bankruptcy Court For The Western District Of Oklahoma Page 5

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4.
I (or the entity I represent) have neither previously received remittance for the
claim nor have contracted with any other party other than the person named in Item 1 above to
recover these funds.
I certify that the foregoing statements are true and correct to the best of my knowledge
and belief.
DATED: _______________________
__________________________________
Creditor/Claimant Signature
Subscribed and sworn to before me this ______ day of _________________, 20___.
My commission expires:
__________________________________
______________________
Notary Public
(Seal)

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