Driver'S License/identification Card Birth Affidavit Form
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1
2State of Maine
Secretary of State – Bureau of Motor Vehicles
DRIVER’S LICENSE/IDENTIFICATION CARD BIRTH AFFIDAVIT
See Reverse for Instructions
Section A – To be completed by the Driver’s License/Identification Card applicant
Name of Applicant Whose Birth is to be proved
Sex
Last
Title (Jr., Sr., III)
Male
First
Middle
Female
Applicant’s Date of Birth (mm-dd-yyyy)
Applicant’s Place of Birth
Name of Applicant’s Parents
Father
Mother
Applicant’s Current Address
Street
Apartment Number
City
State
ZIP Code
Section B – To be completed by person that has knowledge of applicant’s birth.
Number of Years You Have Known the Applicant: ___________________________________
State all the facts you know about the applicant’s birth, including your relationship to the applicant. State how you
obtained the knowledge. Please use additional sheet(s) of paper if more space is required.
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
My name is ______________________________________________. My birth date is __________________.
(Your full legal name)
(Month/day/year)
I presently reside at ___________________________________________ in ___________________________.
(Street Address)
(City and State)
My phone numbers where I can be reached are: Home:_____________________; cell:___________________;
work:____________________. I am usually at work from _____________ a.m./p.m. to ___________a.m./p.m.
My mailing address is :
same as above or:
_________________________________________________________________________________________.
(check the box if same as above, or insert complete mailing address if different from your street address)
Subscribed and sworn to under pains and penalties of perjury.*
Signature: ____________________________________________________ Date: ______________________
*By signing this statement, I verify that the representations herein are true. By making false statements on
this document, I realize I am committing a Class D crime punishable under Maine law.
Maine Bureau of Motor Vehicles staff may contact you, the Affiant, to verify the information provided.
Section A Instructions – to be completed by the driver’s license/ID card applicant.
101 Hospital Street 29 State House Station
Augusta, Maine 04333
207-624-9000 ext. 52114 TTY Users Call Maine Relay 711
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