Any report, form or assurance required to be submitted to the state by a town officer which requires the submitting officer to certify to the accuracy of information it contains shall use a statement for the certification in a form substantially similar to the following: “The information submitted on this form is a true and accurate statement to the best of my personal knowledge and belief based on the information available to me at the time entered hereon and no information is presently known by me to exist which leads me to believe or suspect otherwise.”