You are on page 1of 2


To Whom It May Concern,

I, the undersigned, ORAWAN SOMBOUNE, was born on April 14,1963.

I am residing at No. 8/31 Burapa 7, Moo 5, Srikan, Donmueang Bangkok,

I ,hereby, declare that: Since the year of 1995, I had cohabited with Mr.
CHUSAK PHUTTHARAK, who was born on August 10,1965. We lived
together without register for marriage until the year 2004, our cohabitation

We have a common daughter name : ONVANYA PHUTTHARAK

Date of Birth: 12/27/1997
Place of Birth: Bangkok, Thailand.

I, ORAWAN SOMBOUNE, give my consent to my daughter to come to

the United States to live with her father.

I certify that the above declaration is true and correct. I can be prosecuted
before the court of law for any false statement.

Following are two witnesses, who acknowledge my situation and the

cohabitation between myself with MR. CHUSAK PHUTTHARAK.

Sincerely yours,

Orawan Somboune

First Witness Second Witness

Full name: Weera Phuttharak Full name: Arree Veerasai

Date of Birth: 08/1961 Date of Birth: 02/26/1943
ID No. 5331090005529 ID No. 3101401744081
Address: 111/250 Ammarinnvet 3, Address: 111/250 8/31 Burapa 7,
Saimai Rd, Saimai District, Moo 5 Srikan, Donmueng ,
Bangkok, Thailand Bangkok,Thailand

__________________ ________________________
Signature of witness Signature of witness