AFFIDAVIT OF BIRTH

State of ________
County of ________

§ 1. Affiant. I, ________, being of legal age and of sound mind, residing at ________, having been first duly sworn upon oath according to law, do hereby depose, declare, and certify under penalty of perjury as follows.

§ 2. Identity and Competency of Affiant.

(a) I was born on ________ in ________.
(b) I am competent to testify to the matters stated herein, and each of the statements set forth in this Affidavit is made upon my own personal knowledge.
(c) My relationship to the individual named in § 3 below is: ________.

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Full Legal Name: ________
Gender: ________
Date of Birth: ________
Age: ________ years
Place of Birth (City and State/Country): ________
Current Address: ________
Citizenship: ________
Marital Status: ________

§ 4. Statement of Facts.

(a) I have known the Subject, ________, since ________.
(b) I declare that the Subject was born on ________ at ________.
(c) The Subject was born to the following parent(s): ________.

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________

§ 6. Purpose of Affidavit. This Affidavit of Birth is being executed and submitted for the following purpose(s):

________

§ 7. Declaration Under Penalty of Perjury. I declare under penalty of perjury under the laws of the State of ________ and of the United States that I have read this Affidavit, that I know and understand its contents, and that the foregoing statements are true, correct, and complete to the best of my knowledge, information, and belief. I understand that any willful false statement made herein is subject to the penalties prescribed by law for perjury.

§ 8. Execution. Executed this ________ day of ________, ________, at ________.

______________________________
________, Affiant

______________________________
Date

ACKNOWLEDGMENT / JURAT

STATE OF ________

COUNTY OF ________

On this ________ day of ________, ________, before me, the undersigned officer, personally appeared ________, who is personally known to me or who proved to me on the basis of satisfactory evidence (namely, ________) to be the person whose name is subscribed to the within instrument, and who, being by me first duly sworn, did acknowledge to me that he or she executed the same for the purposes therein contained, and did swear or affirm that the statements contained therein are true and correct.

I certify under penalty of perjury that the foregoing is true and correct.

In witness whereof, I hereunto set my hand and official seal.

______________________________
Notary Public Signature

______________________________
Printed Name of Notary Public

My commission expires: ________

Commission Number: ________

(Notary Seal / Stamp)