STATE OF ILLINOIS

COUNTY OF [County Name]

Introduction:

I, [YOUR NAME], born on [Date of Birth], currently residing at [YOUR ADDRESS], being duly sworn, depose and say:

Statement of Facts:

1. I am the individual named in the documents presented in support of the application for [Type of License] License.

2. My Social Security Number is [SSN] (if applicable).

3. I have been a resident of [City/Town Name], Illinois, for [Number of Years/Months] prior to this affidavit's date.

4. I affirm that I am not impersonating, nor have I impersonated, any other individual for the purpose of misleading, defrauding, or any other unlawful act.

5. To the best of my knowledge, all information provided in this affidavit, and all documents submitted in support of my [Type of License] License application, are true, accurate, and complete.

6. I understand that providing false information within this affidavit may result in legal penalties, including but not limited to fines, denial of application, or criminal prosecution.

7. This affidavit is executed for the sole purpose of applying for a [Type of License] License as required by the State of Illinois and [Relevant State Department or Agency].

Acknowledgement:

I hereby authorize [Agency or Department Name] to verify the information provided in this affidavit.

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 passport ID as identification.

[NOTARY PUBLIC NAME]

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