I, [YOUR NAME], hereby declare and affirm under penalty of perjury that I am a resident of the state of Georgia, residing at [YOUR ADDRESS].

I am submitting this Affidavit of Residency to [AGENCY NAME] to attest to my residency status for the purpose of obtaining utility services. I understand that accurate residency information is crucial for the provision of utility services and that any false statements made in this affidavit may result in legal consequences.

Details of Utility Service Provider:

• Utility Service Provider Name: [UTILITY COMPANY NAME]

• Type of Utility Service(s) Requested: [UTILITY TYPE]

I affirm that the address provided above is my primary and permanent residence. I am the lawful occupant of this residence and bear full responsibility for the utility services requested herein.

Furthermore, I acknowledge that providing false or misleading information on this Affidavit of Residency may result in the termination of utility services and may subject me to civil and criminal penalties.

I hereby authorize [AGENCY NAME] to verify the information provided in this affidavit through any means necessary, including but not limited to contacting the utility service provider, conducting site visits, or requesting additional documentation.

I declare that all the information provided in this Affidavit of Residency is true and correct to the best of my knowledge and belief.

Signed by:

[YOUR NAME]

Witnessed by:

[WITNESS' NAME]

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