STATE OF MONTANA

COUNTY OF [County Name]

Introduction:

I, [YOUR NAME], being duly sworn, depose and state:

Statement of Facts:

1. I, [YOUR NAME], born on [Date of Birth], hereby declare under oath my personal details necessary for the Montana Affidavit of Residence.

2. My Social Security Number is [SSN], although provision of this number may be optional depending on the specific requirements of the state health program or social service for which this affidavit is being submitted.

3. I am currently residing at [YOUR ADDRESS], a place I consider my permanent home within the State of Montana.

4. For any necessary correspondence or verification processes, I can be contacted at my telephone number, [YOUR PHONE NUMBER], or via my email address, [YOUR EMAIL ADDRESS].

5. This information is provided in good faith to establish my residency status in Montana for the purpose of qualifying for state health programs or social services exclusive to Montana residents.

6. I hereby declare that I am a resident of the State of Montana, residing at the above-mentioned address within the county of [County Name].

7. I have been living at this address since [Date of Residency Start].

Purpose of Affidavit:

This affidavit is made for the purpose of qualifying for state health programs or social services available exclusively to residents of the State of Montana.

Supporting Evidence:

Attached hereto are copies of documents that serve as evidence of my residency:

• Lease Agreement

• Utility Bill

• Montana Driver’s License

Oath and Affirmation:

I affirm that the information provided in this affidavit is true and correct to the best of my knowledge.

I understand that providing false information on this affidavit can result in penalties under law.

Signed this [DAY] of [MONTH], [YEAR].

Signature:

[YOUR NAME]

Subscribed and sworn to (or affirmed) before me this [DAY] of [MONTH], [YEAR], by [YOUR NAME], who is personally known to me or has produced valid driver's license as identification.

[NOTARY PUBLIC NAME]

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