STATE OF KENTUCKY

COUNTY OF [County Name]

Introduction:

Before me, the undersigned notary public, personally appeared [YOUR NAME], who being duly sworn according to law, deposes and says:

Statement of Facts:

1. The undersigned, [YOUR NAME], born on [DOB], hereby affirms and declares. Residing at [YOUR ADDRESS], I am duly recognized by my legal identification number, which could be any of the following: driver's license, state identification, or passport number, specifically listed as [Driver's License/State ID/Passport Number].

2. This document is prepared to assert my identity and the details herein for purposes as may be required legally or otherwise.

3. I, [YOUR NAME], hereby affirm that I am legally competent to make this affidavit and swear that the above-mentioned personal information is true and accurate to the best of my knowledge.

4. I understand that this affidavit is made for the purpose of verifying my identity [or state] for the application of a Building Permit with the City Planning Department.

Further Affirmation:

I further affirm that I understand the contents of this affidavit fully and make this declaration conscientiously believing it to be true and correct.

Penalty of Perjury:

I understand that this affidavit is made under the penalties of perjury and is executed voluntarily without any coercion for the purposes stated herein.

IN WITNESS WHEREOF, I have hereunto set my hand and seal on this [DAY] of [MONTH], [YEAR].

Signature:

[YOUR NAME]

Subscribed and sworn to before me this [DAY] of [MONTH], [YEAR].

[Notary Public’s Name]

Seal:

[Notary Seal or Stamp]

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