AFFIDAVIT

STATE OF __________ )
COUNTY OF ________ )

I, _____________________, resident of _____________________, ______________,

____________________, ___________, do hereby solemnly affirm and declare as follows:

1. May name is____________________, I was born in _________________ (city, country)

on ____________ (Month, Date, Year).

2. That my son, ____________________, was born on the ____________ day of

___________________ at the township of __________________, State of
______________, ______ (country), from my wedlock with ______________________

3. That his name at the time of her birth was ________________________;

4. That his birth was never registered with the government (if possible please explain why).

Verification:

I further solemnly affirm and declare that the statements made above are true and correct to the
best of my knowledge and belief, and nothing has been concealed therein.

Solemnly affirmed at _______________, on this _______ day of __________, 2017.

____________________
DEPONENT

ATTESTED: