I, ____, being duly sworn, say that to the best of my knowledge, information and belief, the foregoing statement contains a full, true and complete list of all property held or belonging to me (or to me as a partner, or in my possession as trustee, administrator, guardian, or agent) in the Virgin Islands, and that such property has been fully and fairly described and its true condition and value represented; and that all interrogatories relating thereto have been fully and truthfully answered; that I have in no case sought to mislead said Tax Assessor as to the quantity or quality of said property.
____Subscribed and sworn to before me this ____ day of ____ 19____
Tax Assessor.