I, [Your Name], residing at [Your Address], solemnly affirm and declare under penalty of perjury under the laws of [Your State], that the following statements are true and correct to the best of my knowledge, information, and belief:

• I am a citizen of [Your Country].

• I was born on [Birthdate] in [Birthplace], as evidenced by my birth certificate, a copy of which is attached hereto and marked as Exhibit A.

• I have resided continuously in [Country of Birth] until [Date of Immigration].

• I immigrated to [Current Country of Residence] on [Date of Immigration] under [Visa Type].

• I have not relinquished my citizenship in [Country of Birth], and I remain a citizen of [Country of Birth].

• I understand the importance of providing truthful information in this affidavit and acknowledge that any false statements may result in legal consequences, including but not limited to the denial of immigration benefits or prosecution for perjury.

I, [Your Name], do solemnly swear that the contents of this document are accurate and truthful to the best of my knowledge and belief. I reaffirm my oath and declare it before a competent legal authority this [Date].

[Your Name]

[Your Address]

[Date]

State of [Your State]
County of [Your County]

On this [Day] day of [Month], [Year], before me, the undersigned notary public, personally appeared [Your Name], known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument, and acknowledged to me that he/she executed the same in his/her authorized capacity and that by his/her signature on the instrument, the person or the entity upon behalf of which the person acted, executed the instrument.

[Notary Stamp]

[Notary Public Name]
My Commission Expires: [Date]

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