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)
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