(AFFIX SECURELY TO CLAIM)
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State of New York
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______________________________ County
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certifies that the articles, materials or services
charged in the annexed bill or account were actually sold, delivered
or furnished to the City of Middletown, on the order of _____________________________________
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at the dates and for the prices therein named,
which were fair, just and reasonable prices for the same; that the
labor and services therein charged were actually rendered and performed
on the like order, and the prices charged therein are fair and reasonable
prices for such services; that said bill is just and true; that there
is due thereon $_____________ and no part of the same has been paid;
and there is no setoff or counterclaim against the same.
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