STATE OF OREGON

COUNTY OF [County Name]

Introduction:

I, [YOUR NAME], being duly sworn, declare under penalty of perjury as follows:

Statement of Facts:

1. I, [YOUR NAME], born on [Date of Birth], currently residing at [YOUR ADDRESS], hereby affirm my identity for the purpose of this affidavit.

2. My identity can be verified through my [Type of Identification], which bears the number [Identification Number].

3. This affidavit is executed with the purpose of correcting an official record or document.

4. The purpose of this affidavit is to correct a name or other detail on my official record or document. The specific detail to be corrected is as follows:

   • Document/Record Holding Incorrect Detail: [Name of the Document]

   • Incorrect Detail Presently on Record: [Detail as it currently appears]

   • Corrected Detail: [Detail as it should correctly appear]

5. The reason for the correction is a legal name change that occurred subsequent to the creation of the original record.

Supporting Documents:

Attached hereto are copies of supporting documents that evidence my identity and the need for the correction as stated.

These may include, but are not limited to, a legal name change document, birth certificate, or other government-issued identification showing the correct detail.

Acknowledgement:

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

I understand that this affidavit is made for the purpose of correcting an official record or document and may be subject to verification by the issuing authority.

Executed on this day of [Day], [Month], [Year].

Signature:

[YOUR NAME]

Subscribed and sworn to (or affirmed) before me this [Day], [Month], [Year], by [YOUR NAME], proved to me on the basis of satisfactory evidence to be the person who appeared before me.

[NOTARY PUBLIC NAME]

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