AFFIDAVIT BY [Close Relative's First Name] [Close Relative's Last Name]

Re: [Applicant's First Name] [Applicant's Last Name] (If child is married, list the following: (Applicant's Maiden Name: Applicant's Maiden Name))

I,  [Close Relative's First Name] [Close Relative's Last Name], hereby depose and say:

1. That I, [Close Relative's First Name] [Close Relative's Last Name], was born on [date] in the town/city of [City], [Country].
2. My full and complete address is [street address with apartment or house number, town/city, state, postal zip code].
3. That I am closely related to [Applicant's First Name] [Applicant's Last Name]. I am his/her [fill in: uncle, aunt, grandparent, etc.]
4. That [Applicant's First Name] [Applicant's Last Name] was born on [date] in [name of city], [country] to [Mother's First Name] [Mother's Last Name] and [Father's First Name] [Father's Last Name].
5. That I have direct personal knowledge of the event and circumstances concerning the birth of [Applicant's First Name] [Applicant's Last Name] because [state how you are aware of the birth or birth date].
6. That I have known the applicant since [month/year].
7. This affidavit is being submitted because [CHOOSE ONE] there is no official record of birth [OR} the official record of birth is incomplete concerning [Applicant's First Name] [Applicant's Last Name].

I declare under penalty of perjury, that the foregoing is a true and correct statement.

_________________________
[Close Relative's First Name] [Close Relative's Last Name] and signature

 

Subscribed and Sworn to before
Me, this ____ day of __________,
[YEAR] at ______________________.