SWORN STATEMENT AFFIDAVIT - MOTHER
(Please print as listed on Birth Certificate)
Applicant’s Date of Birth: Applicant’s State of Birth:
NOTE: If applicable, list reason why biological Indian parent was unable to sign this affidavit.
Biological Mother’s full Maiden Name:
(Married Last Name)
Biological Father’s full Name:
I do solemnly swear I am the biological mother to the applicant. To the best of my knowledge
the information listed above is true and correct and no ADOPTION has taken place.
(Signature of Biological Mother)
(To be completed by Notary Public)
Subscribed and sworn to before me this day of 20
Notary Signature My Commission Expires
1001. Statements or entries generally
Whoever, in any matter within the jurisdiction of any department or agency of the United States
knowingly and willfully falsifies, conceals or covers up by any trick, scheme, or device a
material fact, or makes any false, fictitious or fraudulent statements or representations, or makes
or uses any false writing or document knowing the same to contain any false, fictitious or
fraudulent statement or entry, shall be fined not more than $10,000 or imprisoned not more than
five years or both.
P.O. Box 948
Tahlequah, OK 74465-0948