STATE OF [Your State]

COUNTY OF [Your County]

I, [Your Name], of legal age, and currently the [Your Job Title] of [Your Nursing Home Name], located at [Your Company Address], being duly sworn, depose and say:

1. Facility Details:

[Your Nursing Home Name] operates as a fully licensed and accredited facility, offering a wide array of comprehensive care services tailored to meet the diverse needs of our residents. Our services include, but are not limited to:

• Medical Support: We provide round-the-clock medical monitoring and care, managed by a team of licensed physicians and medical professionals.

• Nursing Care: Our skilled nursing staff deliver continuous care, including medication administration, wound care, and chronic disease management.

• Personal Assistance: We offer support for daily living activities such as bathing, dressing, eating, and mobility, respecting the dignity and preferences of each resident.

The facility complies with all relevant state and federal regulations, ensuring the highest standards of safety, quality, and care are maintained. Accredited by [Relevant Accreditation Body], [Your Nursing Home Name] is authorized to operate within the jurisdiction of [Your County], [Your State], upholding the principles of excellence and compassion in elder care.

2. Resident Verification:

I affirm that [Your Client Name], with the birthdate of [Date], formerly residing at [Your Client Previous Address], has been a resident under the care of [Your Nursing Home Name] continuously since [Residency Start Date]. The verification process has confirmed that:

• Identity Accuracy: All personal details of the Resident, including full name, date of birth, and previous address, are accurately recorded and maintained in our secure administrative records.

• Document Review: Relevant identification documents have been reviewed and authenticated to ensure the accuracy of the recorded information.

• Compliance with Regulations: Our record-keeping practices adhere to state and federal guidelines to ensure the integrity and confidentiality of resident information.

3. Purpose of Residency Affirmation:

This affidavit is executed at the behest of [Your Client Name] or their duly appointed legal representative to formally affirm the residency of [Your Client Name] for specific purposes. These include, but are not limited to:

• Local Voting Ballot Registration: Ensuring the Resident's eligibility to vote in local elections within [Your State/County].

• State Benefits Registration: Facilitating the application or continuation of state benefits, affirming the Resident's local residency as required by state law.

• Medical Record Transfers: Authorizing the transfer of medical records to healthcare providers or facilities, as necessitated by the Resident’s care needs.

4. Continuity of Residency:

The Resident continues to reside at our facility and there are no immediate plans, to the best of our knowledge, for the Resident to relocate. Any change in the residency status of [Your Client Name] will be recorded and reported in accordance with state regulations and facility policies.

5. Legal Authority and Accuracy of Information:

I affirm that the information provided in this affidavit is accurate to the best of my knowledge. I am authorized to attest to the residency status of the inhabitants of [Your Nursing Home Name] and am aware that providing false information in this affidavit can result in penalties under state and federal law.

6. Execution:

This affidavit is executed to serve as an official and lawful declaration of [Your Client Name]'s residence at [Your Nursing Home Name], confirming their status as a resident for legal and administrative purposes as stated herein.

SWORN TO AND SUBSCRIBED before me this [Month Day, Year].

[Your Job Title]

[Your Company Name]

Notary Public:

State of [Your State]

My commission expires [MM-DD-YYYY].

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