I, A.B. (the name of the party claimant) of _______, in the county of _______ and State of _______, (or as the case may be) do hereby affirm and declare that I have acquired title in fee, by twenty-one years adverse possession, to the following described land, situate in _______, in the county of _______, and State of Pennsylvania, viz: (Here insert a full and complete description of the land claimed, by metes and bounds, or other sufficient designation). Adverse entry was made upon the said land by me on or about the _______ day of _______, Anno Domini _______, and continued until about the _______ day of _______, Anno Domini _______, (or, where the possession of the claimant is tacked on to that of others who have preceded him, it should be stated as follows: Adverse entry was made upon said lands by _______ on or about the _______ day of _______, Anno Domini _______, who continued in possession until about the _______ day of _______, Anno Domini _______, and was succeeded therein by _______, who continued in possession until about the _______ day of _______ Anno Domini _______, and was succeeded therein by me, who continued in possession until about the _______ day of _______, Anno Domini _______). At the time of said entry C.D. (naming some person or persons in the line of the existing paper or legal title, as nearly as may be the real owner of said lands at the time of such entry), was the owner or reputed owner of the said land, and I claim adversely to him (or them). Witness my hand, this _______ day of _______, Anno Domini _______.

(Signed)