STATE OF [INSERT STATE]

COUNTRY OF [INSERT COUNTRY]

IN THE OF [COURT AND JURISDICTION]

AFFIDAVIT
Case Number:

[INSERT PLAINTIFF] (‘Plaintiff’)

[INSERT DEFENDANT] (‘Defendant’)

I, [INSERT NAME] of [INSERT ADDRESS] do hereby swear under oath that:

1. [INSERT OATH STATEMENT].

2. [INSERT OATH STATEMENT].
3. [INSERT OATH STATEMENT].

Under penalty of perjury, I hereby declare and affirm that the above stated facts, to be the best of
my knowledge, are true and correct.

Dated: [INSERT DATE]

___________________________________

Signature

Printed name:

Date:
 NOTARY OF ACKNOWLEDGEMENT
State of: [INSERT STATE]

Country of: [INSERT COUNTRY] (Seal)

This Affidavit was acknowledged on the [INSERT DATE] by the undersigned, [INSERT UNDERSIGNED
NAME], who has satisfactorily proven to me to be the person whose name is subscribed to this
document.

___________________________________

Signature

___________________________________

Notary Public

My Commission Expires on the: ___________________________________