I, .................., do solemnly swear (or affirm) that the foregoing list is true and correct to the best of my knowledge; that the value affixed to the property therein listed I believe to be the true and actual value thereof; that none of the assets belonging to (here state the name of individual or firm) and used in the business of (here describe the business) have to my knowledge, since the assessment date, been converted into nontaxable securities for the purpose of evading the assessment of taxes thereon; so help me, God.
The officer administering the oath shall append thereto the following certificate:
Subscribed and sworn to before me by (here insert affiant's name) this ........... day of ..................., 20 ......
W. Va. Code § 11-3-15