DECLARATION BY AFFIDAVIT

Having been duly sworn, Affiant declares the following:

1. Affiant stated legal name is:

2. Affiant Date of Birth is:

3. Affiant Social Security number is:

4. Affiant DRIVER LICENSE NUMBER is:

5. Affiant current residence is:

STATE OF FLORIDA
SS: ACKNOWLEDGMENT _____________________________________
COUNTY OF BROWARD

This instrument was acknowledged before me

On ____day of __________, 20______

_________________________________________
Notary Signature

_________________________ Notary Stamp:

Notary Printed Name

_________________________________________
My Commission Expires

DECLARATION BY AFFIDAVIT
My Name:

My Address:

SSN:

DOB:

Driver License: Issued: Expiration:

I affirm according to the law that the information provided on the Affidavit is true and to the best of my
knowledge.

Signature Date:

(Notary Stamp)

Notary Signature