AFFIDAVIT OF OWNERSHIP

State of NEW YORK}

} SS

County of KINGS}

RE: Birth Certificate, Birth No 199-72-309290, Authenticated B.C. No 16292249

I, OWN THE BC the undersigned, first lien holder, beneficial owner, having obtained the age of majority,
depose and state that I am familiar *purchase this template for exact and true affidavit wording*

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Printed name
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Signature

Signed and sworn to before me this ________ day Of February, 2017.

I, __________________________________ A Notary, attest, the person signing this document is also

the person whose image appears above.

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________________________________ Notary Public My Commission Expires