Affidavit Of Birth printable pdf download

Affidavit Of Birth

Dearborn Public Schools

Affidavit of Birth/5111 F1

I, _____________________________, do swear or affirm that I am the

________________________________ of ________________________________

father, mother or guardian

student

and that said child was born on:

______________________________________

month

day

year

I am unable to furnish a certified copy of the student’s birth certificate at this time for the following

reasons:

In lieu of the required certified birth certificate, I am providing the following acceptable items:

_____

non-certified birth certificate

_____

baptismal record

_____

court record

_____

doctor or hospital record

_____

sworn Government Records, i.e. passport, immigration papers, refugee identification cards etc.

_____

certified citizenship paper

_____

other (Must be approved by Student Services)

In the absence of any documents that may be supported by this affidavit, I understand that failure to

produce an official birth certificate within 30 days will lead to a referral to the local law enforcement

agency for investigation.

_________________________________________

_______________

Signature of Parent/Guardian

Date

8/13

Affidavit Of Birth