AFFIDAVIT OF RESIDENCE

State of ________
County of ________

BEFORE ME, the undersigned authority, personally appeared the Affiant named below, who, being first duly sworn upon oath and being of lawful age and competent to testify, did depose and state as follows under penalty of perjury:

§ 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:

________

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________

§ 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: ________