STATUTORY DECLARATION IN LIEU OF BIRTH CERTIFICATE by LJ60j3Nr

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									STATUTORY DECLARATION IN LIEU OF BIRTH CERTIFICATE

I, the undersigned Mr. [name], now living at [address], in the city of [city], State of [state].

Solemnly declare that:

1. My date of birth was:

2. My place of birth was: .

3. My father's full name :

4. My mother's full name is:


5. I make the present statutory declaration in-lieu of birth certificate because my original birth
certificate has been lost and I am unable to obtain a new one due to the distance that separates
Vietnam from the United States.

IN WITNESS WHEREOF, I have signed in [city], this [date], 2008




____________________________________
[signature]



Solemnly declared before me in
[city], on this [date],
2008



______________________________
Public Notary

								
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