No claim against the insolvent's estate shall be allowed unless the claimant, or some one for him if he cannot do so, shall furnish to the assignee or receiver a statement of his claim, together with a copy of any book entries appertaining thereto, or any note or other writing evidencing the same, verified by an affidavit in the following form:

I, G.H., do solemnly swear (or affirm) that the above is a true statement of my claim against the insolvent estate of E.F.; that there are no credits or allowances thereagainst, except as therein set forth; that I have not directly or indirectly made or entered into any bargain, arrangement or agreement, express or implied, to take or receive, directly or indirectly, any money, property, or consideration whatever, to or for myself, or to or for any other person, firm or corporation whatsoever, other than my dividend as a creditor of said estate, and that there is no collateral security for said indebtedness or any part thereof, held by me or any one else, other than as above set forth. So help me God (or, and so I do affirm).