Affidavit OF SINGLE STATUS

TUYN TH c thn

On this date of
Vo ngy

. . . . . . . . . . . . . .
dd mm yyyy

, I, the undersigned,
, ti, ngi k tn di y,

Full Name:
H v tn:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nam:
Male

N:
Female

Date of Birth:
Ngy sinh:

. . . . . . . . . . . . .
dd mm yyyy

Place of Birth:
Ni sinh:

. . . . . . . . . . . . . . . . . .

Social Security Number:

S th an sinh x hi:

. . . . .

. . . . .

US Passport (or Green Card) No: . . . . . . . . . . . .

S h chiu / th xanh

Current Occupation:
Ngh nghip hin nay

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( . ) . . . . . .

Employer (Name, Add, Tel):

Ni lm vic (Tn, a ch, in thoi)

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a ch thng tr:

Permanent Address (Str. Add, City, State, Tel): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ( . ) . . . . . . being duly sworn in, hereby solemnly declare that, under the law of the United States, I am currently single, have never been married (or was divorced/widowed on . . . . . . . . . . . . . . . . . . . . . . . and have never been remarried since that date) and fully qualified to marry the following Vietnamese citizen:
xin tuyn th, theo lut php Hoa K, ti hin c thn, cha tng kt hn bao gi (hoc li hn/ga t . cha ti gi t ti nay), v hi iu kin kt hn vi cng dn Vit Nam c tn di y: . . . . . . v

Full Name:
H v tn:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . Nam:
Male

N:
Female

Date of Birth:
Ngy sinh:

. . . . . . . . . . . . .
dd mm yyyy

Place of Birth:
Ni sinh:

. . . . . . . . . . . . . . . . . .

ID Card Number: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
S CMND:

Permanent Address: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
a ch thng tr:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I declare that the statements made in this affidavit are true and correct and I take full responsibility for them under US law of perjury. I also declare that I shall marry the above-named person according to the law of Vietnam.
Ti xin cam oan nhng li tuyn th trn l ng s tht v xin chu trch nhim v nhng li tuyn th trc lut php Hoa K. Ti xin cam oan s kt hn vi cng dn Vit Nam c tn trn theo lut php Vit Nam.

Signature of the Affiant: Full Name in Print:

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ngi tuyn th k v ghi y h tn:

For the Notary Public Phn dnh cho Cng chng vin Sworn to and subscribed before me on this . . . day of . . . . . . . . . . . . . . . . . . . . . . . . .
Tuyn th v k tn trc mt ti ngy