Affidavit Of Birth Form

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AFFIDAVIT OF BIRTH
State of MINNESTOA______)
County of RAMSEY________)
1. I, [Witness Name], was born on [MM/DD/YYYY], in [City/Country of Birth].
2. [Have witness explain his or her immigration status if applicable. Have witness explain his or her
status at entry into the United, A number, and current status.]
I hereby certify that, [CLIENT’S NAME] was born on [DOB] in [Insert City] Thailand.
3.
4. Applicant’s mother’s name is [MOTHER’S NAME].
5. Applicant’s father’s name is [FATHER’S NAME].
6. My relationship to the Applicant is ___________________.
7. I can confirm the date and place of birth for [CLEINT’S NAME] as well as her parents’ identities
because [HAVE WITNESS EXPLAIN THAT HE OR SHE WAS EITHER PRESENT DURING
OR DIRECTLY FOLLOWING THE BIRTH. Example: “I was present during the labor of
[Child’s Name] to assist the family with various needs during the child birth.” If WITNESS WAS
NOT PRESENT DURING OR DIRECTLY FOLLOWING THE BIRTH HAVE THEM
EXPLAIN WHEN THEY LEARNED ABOUT THE BIRTH AND HOW THEY KNOW THAT
THE PARENT CHILD RELATIONSHIP EXISTS]
8. I declare the forgoing is true and correct to the best of my knowledge and ability.
9. I am aware that providing misleading information can result in the denial of the immigration
application.
Signature______________________________________________ Date________________
Printed Name:_______________________________________________________________
Address____________________________________________________________________
Signed and sworn before me
this______day of____________of ____________.
_________________________________________
Signature of Notary Public
My Commission expires: _____________________.

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