AFFIDAVIT OF RESIDENCE
State of ________
County of ________
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§ 1. Identity of Affiant. My full legal name is ________ (the “Affiant”).
§ 2. Date of Birth. My date of birth is ________.
§ 3. Current Residence. I currently maintain my primary and permanent place of residence at the following address (the “Residence”):
________
§ 4. Mailing Address. My mailing address, if different from the Residence, is:
________
§ 5. Duration of Residence. I have continuously resided at the Residence for the following period of time: ________, having first established residence on or about ________.
§ 6. Co-Residents. The following individuals, together with their respective relationships to me, also reside at the Residence:
________
§ 7. Proof of Residence. In further support of this Affidavit, I have provided the following documentary evidence establishing my residence at the Residence:
________
§ 8. Identification. For purposes of identification before the Notary Public, I have presented the following valid, government-issued form of identification:
________
§ 9. Purpose. This Affidavit of Residence is being made and sworn voluntarily for the following purpose:
________
§ 10. Declaration of Truth. I hereby declare and affirm that all of the foregoing statements and information contained in this Affidavit of Residence are true, complete, and correct to the best of my knowledge, information, and belief, and that this Affidavit is made for the purpose stated herein. I understand that any willfully false statement made herein subjects me to the penalties of perjury under the laws of the State of ________ and any applicable laws of the United States.
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FURTHER AFFIANT SAYETH NAUGHT.
Executed on this ________ day of ________, ________.
Affiant Printed Name: ________
Affiant Signature: _______________________________
ACKNOWLEDGMENT / JURAT
State of ________
County of ________
Subscribed and sworn to (or affirmed) before me on this ________ day of ________, ________, by ________, who personally appeared before me and 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 foregoing instrument, and who acknowledged to me that he, she, or they executed the same for the purposes therein stated.
I certify under PENALTY OF PERJURY under the laws of the State of ________ that the foregoing is true and correct.
WITNESS my hand and official seal.
(Notary Seal / Stamp)
Notary Public Signature: _______________________________
Notary Printed Name: ________
Notary Commission Number: ________
My commission expires: ________