Name _
Street Address City, State
Zip
Date
To Whom This May Concern,
I, _ _, hereby attest and claim the individual known as _ _ resides at the street address of __, City of _ _, State of
and has since _ _ , 20_ _.
Furthermore, I swear and affirm under penalty of perjury that the facts set forth in this statement are true and accurate.
Sincerely,
_
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
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
