Rhode Island General Laws Title 10. Courts and Civil Procedure--Procedure in Particular Actions § 10-13-9. Certificate of justice as to oath

The oath being administered and taken by the prisoner, the justice shall deliver to him or her a certificate thereof under, his or her hand and seal, in the following form:

To ___ warden of the correctional institution at ___ in the county of ___ I, the subscriber, authorized by the statute in such case made and provided, do certify that ___ a poor prisoner confined upon mesne process (or otherwise, as the case may be) in the correctional institution at __________ aforesaid, has caused __________ the party at whose suit he or she was so confined, to be notified according to law, of his or her the said ___ desire of being admitted to take the poor debtor's oath;  that in my opinion the said ___ has not any estate, either real or personal, except what is exempt from attachment by law (or, over $10.00, as the case may be), and that he or she has not conveyed or concealed his or her estate with design to secure the same to his or her own use or to defraud his or her creditors;  and that I have, after due caution to the said ___ administered to him or her the oath (or, affirmation,) prescribed by law to be administered to poor debtors.

Witness, my hand and seal, this ___ day of ___ A.D., ___ Justice of the District Court of the ___ Judicial District.