Sealed and delivered in presence of
J.B. and G.J.
State of __________, County of __________, ss.
On this _____ day of __________, A.D. 18_____, before me, the subscriber, a __________ in and for said county, personally appeared __________ to me known to be the person described in, and who executed the foregoing instrument, and acknowledged that he executed the same as __________ free act and deed.
County of __________, ss. B.B.S. and J.E., being duly sworn, say each for himself, that he is surety in the within bond; that he is a resident and freeholder of the state of __________, and that he is worth the sum of (five hundred) dollars over and above his debts and liabilities, and exclusive of property exempt from execution.
B.B.S. and J.E.
Subscribed and sworn to before me, this _____ day of __________, 18_____.
W.R.P., Justice of the Peace.
(After folding the instrument the approving officer must indorse on its back the following words:) "I hereby approve the within bond and the sureties therein contained, this _____ day of __________, 18_____."
(Signed officially by the approving officer.)