State of
County of
I, , residing at , being duly sworn, testify, and state the following:
Personal information. My identity data are as follows:
Statement of identity. I confirm that the above information accurately reflects my identity.
Legal acknowledgment. Under penalty of perjury I, , solemnly confirm and declare that the information provided in this Affidavit is true and accurate as far as I am aware. I understand that any false statements may have legal consequences.
This Affidavit was made on .
____________________________
(Place for signature)
State of
Acting in the county of
Sworn to and subscribed before me on ___________________________.
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Place for signature
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Notary public's name and seal