AFFIDAVIT

Date: [MM/DD/YYYY]

My legal name is [AFFIANT NAME], the affiant, and acknowledge I am:

• [#] years old.
• A resident in the state of [AFFIANT STATE] with an address of [AFFIANT ADDRESS].

Being duly sworn, I hereby swear under oath that:

[SWORN STATEMENT]

Under penalty of perjury, I hereby declare and affirm that the above-mentioned statement is, to the best of my knowledge, true and correct.

Affiant Signature: ______________________________ Date: _______________

NOTARY ACKNOWLEDGMENT

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of [STATE]
County of [COUNTY]

The foregoing instrument was acknowledged before me, [NOTARY PUBLIC NAME], on [MM/DD/YYYY], by the undersigned, [AFFIANT NAME], who is personally known to me or satisfactorily proven to me to be the person whose name is subscribed to the within instrument.

WITNESS my hand and official seal.

Signature: ________________________

(Seal)