STATE OF [Your State]

COUNTY OF [Your County]

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

1. Facility Representation:

As [Your Job Title] at [Your Nursing Home Name], I am duly authorized to represent the facility in legal matters. [Your Nursing Home Name] is a licensed care facility that complies with all applicable state and federal regulations to provide elder care and supportive services.

2. Resident Information Verification:

I hereby confirm that [Your Client Name], born on [Date] and identified by Social Security Number [SSN] (or other applicable national identification number), is an ongoing resident at [Your Nursing Home Name]. The admission details are as follows:

• Admission Date: [Admission Date]

• Continuous Residency: Confirmed that the Resident has been living continuously at our facility since the date of admission without any interruptions.

This verification ensures that all records maintained within our facility accurately reflect the residency status and personal identifiers of [Your Client Name]. Such data is crucial for managing their care and responding to any queries or requirements from external bodies regarding the Resident's status.

3. Purpose of Identity Affirmation:

This affidavit is meticulously prepared to affirm the identity of [Your Client Name] specifically for critical purposes including, but not limited to:

• Processing Benefit Claims: Ensuring that all benefit claims submitted on behalf of the Resident are accurate and substantiated, facilitating timely and correct benefits processing.

• Legal Documentation: Confirming the Resident’s identity for any legal processes or documentation that may be necessary during their stay at our facility.

• Medical Treatment Authorization: Authorizing necessary medical treatments that require validation of the Resident’s identity to comply with healthcare regulations and internal policies.

The affirmation of the Resident's identity as documented in this affidavit is intended to meet the requirements set forth by governmental agencies, healthcare providers, insurance companies, or legal entities that require verified identity confirmation for their procedures.

4. Document Verification:

In the process of affirming the identity of [Your Client Name], I have conducted a thorough review and verification of the following government-issued photo identifications:

• Types of Identification Reviewed: [specify types of ID, e.g., driver's license, passport].

• Verification Process: Each document was carefully compared against the original for authenticity and consistency with our records. This includes checking the document numbers, expiration dates, and any security features to prevent identity fraud.

Copies of these verified documents have been securely retained in [Your Client Name]'s personal file within our facility. These records are managed in compliance with our data protection policies to ensure their integrity and are accessible for audit or legal review as required by law or our facility's regulations.

5. Accuracy and Truthfulness:

I attest that all information provided herein is true and correct to the best of my knowledge and belief. I understand that providing false information within this affidavit constitutes an offense and is punishable under the laws of [Your State].

6. Execution:

This affidavit is executed to establish a legally binding document affirming the identity of [Your Client Name] for specific legal and administrative uses as outlined above. This affirmation is made with full understanding of my responsibilities and under penalty of perjury.

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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