Make sure that the heading (in the example: signature line) is hidden and not numbered. Now click into the paragraph and create a table similar to the example. For a signature line, you can use several underscores one after the other (____). At the top of the editor bar, set this text paragraph to be left-aligned so that "Place, date" is not left and right with space between them, as would be the case in justification.
In case there are more, but in the amount unknown, parties, you can serialize the table.
