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Back to Forms for 'Medical Consents & Releases'.


AFFIDAVIT

AFFIDAVIT

ESTABLISH RECORD OF UNRECORDED BIRTH BY NON-PARENT

 

AFFIDAVIT

 

State of: ___________________

 

County of: _________________

 

I, _____________________________________ (full name), being sworn, declare that:

 

1.  The full name of the person whose birth is being registered is __________________

________________, a ___________ (male/female).

 

2.  The person whose birth is being registered was born on ____________________ (month & day) ________ (year), at ________________________________________ (address).

 

3.     The full name of the father whose child's birth is being registered is _____________

________________________.  The last known residence of the father is ____________

_____________________________________ (address).

 

4.  The full maiden name of the mother whose child's birth is being registered is ___________  ____________________________________________, and her last known residence is ______________________________________________________ (address).

 

5.  I have firsthand and personal knowledge of the birth of the person whose birth is being registered as follows: ______________________________________________.

 

6.  I am __________ (_____) years of age, and I am related to the person whose birth is being registered as follows: __________________ (exact relationship).  My address is _____________________________________________________________ (address).

 

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

 

 

______________________________                      ____________________

(Signature)                                                                                        (Date)

 

Sworn before me on this ____ day of ___________________ (month), _________ (year).

 

__________________________________

(Notary Public)

 

My Commission Expires: _______________

 



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