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