Affidavit Of Birth

AFFIDAVIT OF BIRTH

STATE OF ____________________
COUNTY OF ____________________

I, ____________________, born in ____________________, aged ____________________ and currently residing at ____________________,

in the county of ____________________ in the state of ____________________,

being duly sworn, do hereby depose and attest that:

1. I am a citizen of this country and over the age of 18.
2. I am attesting on behalf of the Applicant, ____________________ in {his/her} application for ____________________
3. My relationship to the Applicant is ____________________. We have known each other for ____________________ years and I have direct personal knowledge of {his/her} life.
4. The Applicant was born in ____________________ Hospital, on the date of ____________________ at the time of ____________________
5. The name of the Applicant's parents are ____________________ and ____________________
6. This affidavit of birth is offered in lieu of a birth certificate because ____________________

____________________
AFFIANT

Subscribed and sworn to before me this ____________________ day of ____________________ 20 ____________________

____________________
(Notary Public),

____________________ County.

My commission expires ____________________ 20 ____________________