1

State of North Carolina,
County of Guilford.
S.S.

W. G. Shipman, agent for Mrs. Hazel Fisher Shipman, being first
duly sworn deposes and says that he has handled all the funds in connection
with the construction of a residence on the property of his wife, Mrs.
Hazel Fisher Shipman, on Thurston Street in the City of High Point, North
Carolina, on which property the Jefferson Standard Life Insurance Co.
has made a $5,000.00 loan; that all the debts contracred for labor and
material in the contruction of this residence have been paid in full
to date; and that so far as the affiant knows there are no outstanding
claims which could be reduced to a labor's or mechanic's lien.

In witness whereof the said W. G. Shipman has hereunto set his hand
this the 28th day of November, 1913.

W. G. Shipman,
Affiant.

Subscribed and sworn to before me this the 28th day of November,
1913.
J. Allen Austin

[stamped: My Commission Expires March 24. 1914]