SAMPLE AFFIDAVIT

SAMPLE AFFIDAVIT OF
BIRTH BY CLOSE RELATIVE
AFFIDAVIT BY [Close Relative's First Name] [Close Relative's Last Name].

Re: [Applicant's First Name] [Applicant's Last Name] [If applicant had a different name before marriage, add:] (Maiden Name:
[Applicant’s Maiden Name]).

I, [Close Relative's First Name] [Close Relative's Last Name], hereby depose and say:

1. That I, [Close Relative's First Name] [Close Relative's Last Name], was born on [date] in the town/city of [City],
[Country].
2. My full and complete address is [Street, Apartment/House Number, Town/City, State/Province, Country, Postal
Code].
3. That I am closely related to [Applicant's First Name] [Applicant's Last Name]. I am his/her [uncle, aunt, grandparent,
etc.]
4. That [Applicant's First Name] [Applicant's Last Name] was born on [date] in [City], [Country] to [Mother's First Name]
[Mother's Last Name] and [Father's First Name] [Father's Last Name].
5. That I have direct personal knowledge of the event and circumstances concerning the birth of [Applicant's First Name]
[Applicant's Last Name] because [state how you are aware of the birth and/or birth date].
6. That I have known the applicant since [Month, Year].
7. This affidavit is being submitted because [CHOOSE ONE] there is no official record of birth concerning [Applicant's
First Name] [Applicant's Last Name] [OR] the official record of birth is incomplete concerning [Applicant's First Name]
[Applicant's Last Name].

I declare under penalty of perjury, that the foregoing is a true and correct statement.

_________________________
[Close Relative's First Name] [Close Relative's Last Name] and signature

Subscribed and Sworn to before

Me, this [Day] day of [Month], [Year] at [City, Country].

_________________________
[Notary’s Full Name], Notary Public and signature

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