Affidavit re Knowledge of Birth

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					                                   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:




                                                                                                      electronic form 2005
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