The said statement shall be subscribed and sworn to before some officer competent to administer oaths and affirmations, who shall attest the same substantially as follows, viz: County of _______, State of _______SS. Be it remembered, that on the _______, day of _______, Anno Domini _______, before me, the subscriber, (here designate the title of the attesting officer) personally appeared A.B., (naming the claimant) who having been duly sworn, (or affirmed) did declare and say that the facts set forth in his foregoing statement of claim are true, as he verily believes. Witness my hand and official seal, the day and year aforesaid. X.Y., Notary Public (or as the case may be). (L.S.)