AFFIDAVIT
(SWORN STATEMENT)
Date: ________________, 20____
My legal name is ________________ (“Affiant”) and acknowledge I am:
• Age: ____
• Address: ________________________________
• Residency: ________________
Being duly sworn, hereby swear under oath that:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Under penalty of perjury, I hereby declare and affirm that the above-mentioned
statement is, to the best of my knowledge, true and correct.
Affiant’s Signature: _______________________ Date: _____________
NOTARY ACKNOWLEDGEMENT
A notary public or other officer completing this certificate verifies only the identity of the
individual who signed the document to which this certificate is attached, and not the
truthfulness, accuracy, or validity of that document.
State of ________________
County of ________________
On ________________, 20____ before me, ________________, personally appeared
________________ who proved to me on the basis of satisfactory evidence to be the
person whose name is subscribed to the within instrument and acknowledged to me
that they executed the same in their authorized capacity, and that by their signature on
the instrument the person(s), or the entity upon behalf of which the person(s) acted,
executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of
________________ that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature ____________________________ (Seal)
