I Sh./Smt. _________ Son/Daughter/Wife of _________ Resident of _________ do hereby solemnly affirm and declare as under:
1. That I am resident of _________, _________ and presently residing at _________.
2. That my present age is _________ years.
3. That neither I nor my spouse nor any of my deponent children/ relations (including unmarried children) is a member of any other co-operative housing society functioning in _________ or _________.
4. That neither or nor my spouse nor any deponent relations (including unmarried children) has owned either in full or part on leasehold or free hold any plot of land or house in _________ or _________.
5. That neither I nor my spouse is a member of _________ which own either in full or part on lease or free hold basis any plot of land or a house in _________ of _________.
6. That I do not deal with the purchase or sale of immovable property neither as principal nor as agent in the _________.
7. That I will inform within one month the said society as well as the _________, _________, if any plot of land or house is acquired by me or my wife/any of my deponent relations (including unmarried children).
I, the above said deponent do hereby solemnly affirm and declare that the contents of the above pares are correct and true to best of my knowledge and belief and nothing has been concealed or suppressed.
Verified at _________ on this _________ day of _________.