AFFIDAVIT OF SINGLE STATUS Date Filed:

I, ____________________________________________(Your Name), personally appeared before the

undersigned notary public or clerk of court, and under oath or affirmation make the following statements:

Current Address
__________________________________________, ___________________, _______, ____________
(street) (City) (State) (Zip)

Date of Birth: City and Country of Birth

I am a citizen of the following country: Passport Number:

Initial to indicate which applies to you

_____ (initial) I am currently single

_____ (initial) I have never been married

_____ (initial) I was divorced on _________ (date) and have never been married since that date.

_____ (initial) My former spouse is deceased and I have attached a death certificate for that spouse.

SIGNATURE

___________________________________________________ Date ______________

State of Georgia
County of Chatham

Signed and Sworn to (or affirmed) before me on ______________________ (date)

by __________________________________________ (print name of individual making statement)

who proved to me on the basis of satisfactory evidence to be the person who appeared before me.

Type of ID: ___________________________________________

___________________________________________
Signature of Notary Public or Clerk of Court

My Commission Expires _______________