STATE OF OREGON
COUNTY OF [County Name]

Introduction:

I, [YOUR NAME], currently residing at [YOUR ADDRESS], City of [City], County of [County], State of Oregon, being duly sworn, do hereby state and affirm as follows:

Statement of Facts:

1. I, the undersigned, named [YOUR NAME], was born on [DOB] and currently reside at [YOUR ADDRESS].

2. In situations where identification verification is requisite, my unique identification number, which may be a driver’s license, state ID, or passport number, is [Driver’s License/State ID/Passport Number].

3. This affidavit is intended to accurately affirm my identity and residential information for any required legal, official, or personal verification purposes.

4. I am making this affidavit for the purpose of certifying my personal information as follows:

   • I affirm that I have been a resident at the above address since [Date of Residency Start], and intend to maintain it as my permanent residence.

   • I affirm that the above-stated full legal name and date of birth are accurate and true to the best of my knowledge and belief.

   • This affidavit is executed to verify my identity for the purpose of opening a new bank account.
     

Purpose of Affidavit:

This affidavit is executed for the purpose of certifying the above-stated personal information for submission to [Name of the Government Agency or Official Use], for the purpose of identity verification in the application processing for a new passport.

Declaration and Oath

I understand that this affidavit is made under the penalty of perjury. I declare under penalty of perjury under the laws of the State of Oregon that the foregoing statements are true and correct to the best of my knowledge, information, and belief.

Executed on this [DAY] of [MONTH], [YEAR].

Signature:

[YOUR NAME]
Subscribed and sworn to (or affirmed) before me on this [DAY] of [MONTH], [YEAR], by [YOUR NAME].

[Notary Public’s Printed Name]

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