R.I. Gen. Laws § 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.