AFFIDAVIT OF IDENTITY

State of ________

County of ________

I, the undersigned, being first duly sworn upon oath and being of sound mind and lawful age, do hereby depose, attest, and affirm the following facts to be true and correct of my own personal knowledge:

1. Identity of Affiant. My full legal name is ________ (the “Affiant”).
2. Residence. My current residential address is:

   ________

3. Date of Birth. My date of birth is ________.
4. Other Identifying Information. The last four digits of my Social Security Number (or other government-issued identification number) are ________.
5. Proof of Identification. I have presented to the Notary Public the following form(s) of government-issued photographic identification to establish my identity, together with the corresponding document number(s) and date(s) of expiration where applicable:

   ________

6. Purpose of Affidavit. This Affidavit of Identity is made, executed, and sworn for the following purpose:

   ________

7. Aliases and Former Names. The following are any other names, aliases, or former legal names by which I have been known (if none, state “None”):

   ________

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10. Penalty of Perjury. I declare and certify under penalty of perjury under the laws of the State of ________ that the foregoing statements are true and correct, that I am the person described above, and that the signature below is my true and genuine signature.

IN WITNESS WHEREOF, I have hereunto set my hand on this ________ day of ________.

Affiant: ________

Signature: _______________________________

Printed Name: ________

Date: ___________________________________

ACKNOWLEDGMENT AND JURAT

State of ________

County of ________

Subscribed and sworn to (or affirmed) before me on this ________ day of ________, by ________, who is personally known to me or who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument, and who acknowledged to me that he/she/they executed the same in his/her/their authorized capacity, and that by his/her/their signature on the instrument the person 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.

Notary Public Signature: _______________________________

Printed Name of Notary: ________

My commission expires: ________

Commission Number: ________

(Affix Notarial Seal)