Loan Purpose Affidavit

I, the undersigned, _________, being duly sworn hereby declare that the proceeds of the loan made by _________, in the amount of $____, given me this day, ________________, 20 _, will be used for and only for the following purpose(s): ________________.

Under penalty of perjury, I affix my signature to the foregoing this _____________ day of ____________, 20 __.

Date: ____________.