STATE OF INDIANA

COUNTY OF [County Name]

Introduction:

I, [YOUR NAME], born on [Date of Birth], hereby declare under penalty of perjury that I am a legal resident of the State of Indiana and provide this affidavit to affirm my residence and eligibility for state-specific programs, grants, or scholarships.

Statement of Facts:

1. I hereby affirm that my current legal residence is located at [YOUR ADDRESS], where I have resided for [Number of years and/or months].

2. Should my residence at the above address be less than two years, my previous place of residence was [Your Previous Address].

3. This declaration serves as a confirmation of my residential status in the State of Indiana, provided in good faith for the purposes of applying for state-specific programs, grants, or scholarships requiring proof of such residency.

4. I affirm that the above-listed residence is my current, legal place of residence, and I intend to maintain it as my principal place of residence.

5. I understand that this affidavit is made for the purpose of complying with the residency requirements of the [Name of the Grant, Scholarship, or Program].

6. Attached herewith are copies of two or more of the following documents to substantiate my residency claims:

   • Indiana Driver’s License or State ID

   • Utility bills in my name, dated within the last two months

   • Lease agreement or property deed in my name

   • Other: [Specify any other documents you are including]

Declaration:

I understand that providing false information in this affidavit can result in penalties, including but not limited to the denial of the application, repayment of grant or scholarship funds, and possible legal action.

Signature:

[YOUR NAME]

Subscribed and sworn to before me this [Day] of [Month], [Year].

[NOTARY PUBLIC NAME]

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