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SWORN STATEMENT
IN
PROOF OF LOSS

G.A.S File No. [23587-14870] 
Amount of policy at time of loss [15,000.00 Basic]
Date issued [10/14/66]
Date expires [10/14/69]

Policy No. [137PD1035H] 
Company claim No. [blank]
Agent [Ellis Agery] 
Agency at [Columbia S.C.]

To the Commercial Union Insurance Company
At time of loss, by the above indicated policy of insurance, you insured:
[Jasper Johns]
against loss by [Mia Sty]

Terms and conditions of sold policy and of all forms, advertisements, transfers and assignments attached there. 

Time and origin: A [fire] on the [14] day of [November 1966] the cause and origin of the [undetermined origin destroyed dwelling and contents]

Occupancy: The building described, or containing the property described, was occupied at the time of the loss as follows and for an other purpose whatever: [one family dwelling]

Title and Interest: At the time of the loss, the interest of your insured in the property described therein  was [vested with your insured] No other person or persons had any interest therein or incumbrance thereon, except [no exceptions]

Changes: Since the said  policy was issued, there has been no assignment thereof, or change of interest, use, occupancy, possession, location or exposure of the property described, except [no exceptions]

Total Insurance: THE TOTAL AMOUNT OF INSURANCE upon the property described by this policy was, at the time of the loss [$21,000.00] as more particularly specified in the appointment attached, besides which there was no policy or other contract of insurance, written or oral, valid or invalid

Value: THE ACTUAL CASH VALUE of said property at the time of the loss was [blank]

Loss: THE WHOLE LOSS AND DAMAGE was [blank]

Amount Claimed: THE AMOUNT CLAIMED under the above numbered policy is [$21,000.00]

Statements of Insured: The said loss did not originate by any act, design or procurement on the part of your insured, or this affiant, nothing has been done by or with the privity or consent of your insured or this affiant, to violate the conditions of the policy, or render it void, no articles are mentioned herein or in annexed schedules but such as were destroyed or damaged at the time of said loss, no property saved has in any manner been concealed and no attempt to deceive the said company, as to the extent of said loss has in any manner been made.  Any other information that may be required will be furnished and considered a part of this proof.

The furnishing of this blank of the preparation of proofs by a representative of the above insurance company is not a waiver of any of its rights

State of: [blank]

County of: [blank]

Subscribed and sworn to before me this [blank] day of [blank]

Insured: [blank]

Notary Public: [blank]

Form recommended by the
National Board of the Fire Underwriters