EAA has nothing that I can find, I think your statement will work with mods, (make and serial number) is the "N" number and the "and has been found to be in a safe and airworthy condition." will read "in conformance with its letter of limitations"
June 1, 2008; Annual Maintenance Inspection and all repairs carried out as per aircraft inspection check list attached. All work performed in accordance with AC 43.13B.
EDIT: Argh - that article seems to be directed toward Canadians but includes references to FAA regs. Not sure what to make of it.
