Notarized Proof Of Identification (Sworn Statement) printable pdf download

Notarized Proof Of Identification (Sworn Statement)

NOTARIZED PROOF OF IDENTIFICATION

(SWORN STATEMENT)

NOTE: Use this form only if Born/Died in Alton

PART I. ENTER NAME, DATE AND PLACE OF BIRTH/DEATH, AND NAMES OF PARENTS AS INFORMATION APPEARS ON

BIRTH/DEATH CERTIFICATE.

FULL NAME OF PERSON ON RECORD

DATE OF BIRTH/DEATH

PLACE OF BIRTH/DEATH

SEX

(City or County)

MOTHER’S MAIDEN NAME

FATHER’S NAME

(ONLY IF STATED ON BIRTH RECORD)

PART II. ENTER REALTIONSHIP TO PERSON ON RECORD AND THE TYPE OF ID USED.

NAME AND RELATIONSHIP TO PERSON ON RECORD

TYPE AND NUMBER OF ID ACCEPTED WHEN NOTARIZED

AFFIDAVIT OF PERSONAL KNOWLEDGE

PART III. THIS SECTION MUST BE SIGNED IN THE PRESENCE OF A NOTARY PUBLIC.

STATE OF _____________________

COUNTY OF _____________________

____________________________________________________________________________

Before me on this day appeared _

(Name)

_________________________________________________________________________________,

now residing at

(Address)

(City)

(State)

(Zip Code)

who is related to the person named on Part I as ______________________________________________ and who on oath deposes and says

(Relationship)

that the contents of this affidavit are true and correct.

_________________________________________

Signature

Sworn to and subscribed before me, this ___________ day of ________________________________, 20________.

Signature of Notary Public

(Personalized Seal)

Commission Expires

Typed or Printed Name

Street Address

City, State and Zip

WARNING: ITS IS A FELONY TO FALSIFY INFORMATION ON THIS DOCUMENT. THE PENALY FOR KNOWINGLY MAKING A FALSE

STATEMENT ON THIS FORM OR FOR SIGNING A FORM WHICH CONTAINS A FALSE STAMENT IS 2 TO 10 YEARS IMPRISONMENT AND A

FINE OF UP TO $10,000. (HEALTH AND SAFEY CODE, CHAPTER 195, SEC. 195.003)

MAIL THIS SWORN STATEMENT, APPLICATION, PAYMENT AND A PHOTOCOPY OF YOUR VALID PHOTO ID TO:

CITY OF ALTON VITAL STATISTICS

509 S ALTON BLVD

ALTON TX 78573

(MAIL REQUEST APPLICATIONS WITHOUT PHOTO ID AND SWORN STATEMENT WILL NOT BE PROCESSED)

Rev. 09/2015

Notarized Proof Of Identification (Sworn Statement)

Related Articles

Related forms

Related Categories