This is a document that can be used for a variety of purposes to provide a voluntary
sworn statement under the penalty of perjury. The person making the sworn statement,
or the affiant, must be mentally competent and over eighteen (18) years old.
Additionally, this document must be certified by a notary public to ensure the proper
identification of the affiant. This document can be useful for depositions, interrogatories,
or any other instance when an individual may be required to provide a sworn statement.
STATE OF __________________
COUNTY OF ________________
I, (Name), residing at (address) does hereby swear under penalty that:
1. I am over 18 years of age and competent enough to testify of my own knowledge of the facts
2. All the facts stated by me herein are true, correct and complete to the best of my knowledge
3. [Briefly describe the Statement of facts for which Affiant is witnessing, e.g., residential
witness or witness for a will or witness for signature or a witness of the occurring of a fact.]
IN WITNESS WHEREOF, I have hereunto set my hand and seal on this ____ day of
Before me, the undersigned authority in and for ________________ County and
______________ State personally appeared __________________ (Affiant) who is known to me
and who swore to and subscribed before me this ___ day of _________, 20____.
My Commission Expires: ____________________
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