Nursing Home Notarized Affidavit

Affiant Details

1. Affiant's Name: [Your Name]

2. Affiant's Address: [Your Address]

3. Relationship to Resident: [Relationship to Resident]

Resident Details

1. Resident's Name: [Resident's Name]

2. Nursing Home Name: [Your Company Name]

3. Nursing Home Address: [Your Company Address]

4. Date of Admission: [Month Day, Year]

Statement of Facts

I, [Your Name], solemnly declare and affirm the following under penalty of perjury:

1. The resident, [Resident's Name], was admitted to [Your Company Name] on [Month Day, Year].

2. The resident's physical and mental health condition at the time of admission was assessed as requiring assistance with activities of daily living due to advanced age and mobility issues.

3. The resident requires assistance with bathing, dressing, and medication management.

4. The resident's stay at [Your Company Name] is ongoing as of the date of this affidavit.

I, as the affiant, have personal knowledge of the facts stated herein and declare them to be true and correct to the best of my knowledge and belief.

Signed and sworn to before me on this [Month Day, Year]:

[Your Name]

Notary Acknowledgement

On this [Month Day, Year], before me, a Notary Public in and for said state, personally appeared [Your Name], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that they executed the same for the purposes therein contained.

IN WITNESS WHEREOF, I hereunto set my hand and affix my official seal.

[Name of Notary Public]

Notary Public, State of [State Name]

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