FAMILY MEMBER AFFIDAVIT OF RESIDENCE
Name _________________
Street Address _________________
City, State _________________
Zip _________________
Date _________________
To Whom This May Concern,
I, _________________ [Family Member’s Name], the _________________ [Relation] of
_________________ [Resident] formally acknowledge their residence at the street address of
_________________, City of _________________, State of _________________ since
_________________, 20____.
Furthermore, I swear and affirm under penalty of perjury that the facts set forth in this statement
are true and accurate.
Sincerely,
_____________________
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Witness Acknowledgment
I/We, as witness(es) to the aforementioned claims made by _________________ and
acknowledge their residency status.
Witness Signature _____________________ Date _________________
Print Name _________________
Witness Signature _____________________ Date _________________
Print Name _________________
Notary Acknowledgment
State of _________________
County of _________________
On _________________, before me, _________________, Notary Public, personally appeared
_________________ who proved to me on the basic of satisfactory evidence to be the
person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me
that he/she/they executed the same in his/her/their authorized capacity(ies), and that by
his/her/their signature(s) 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 in the State of _________________
that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Signature _____________________
Place Notary Seal Above Print Name _________________
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.
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