I, [Full Name of Affiant], being of sound mind and acting under oath, hereby declare the following information to be true and accurate to the best of my knowledge and belief.

Identification of Affiant

• Name: [Full Name of Affiant]

• Date of Birth: [Date of Birth]

• Current Address: [Current Address, if different]

• Relationship to Resident: [e.g., Spouse, Daughter, Legal Guardian]

Identification of Nursing Home

• Name: [Your Company Name]

• Address: [Your Company Address]

• Contact Information: [Your Company Number], [Your Company Email]

Confirmation of Residency

I, [Full Name of Affiant], hereby confirm that my mother, [Name], has been a resident of [Your Company Name] from [Date], to the present date, [Date]. During this period, she has received continuous care and assistance from the staff at [Your Company Name].

Witness Statement

I declare that I have signed this affidavit in the presence of [Witness's Name], who is not related to me by blood or marriage and who has no financial interest in the matter.

Notarization

Signed under oath by:

[Full Name of Affiant]

[Date]

State of [Your State], County of [Your County]

On this [Date], before me, the undersigned notary public, personally appeared [Full Name of Affiant], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he executed the same for the purposes therein contained.

Notary Public, [State]

My Commission Expires: [Expiration Date]

Legal Disclaimer

I comprehend that if I make a false statement in this affidavit, it is treated as perjury. This means that I am completely aware that providing incorrect or misleading information is against the law and could potentially lead to legal consequences or punishment that may be enforced against me.

Contact Information:

[Full Name of Affiant]

[Affiant's Number]

[Affiant's Email]

I affirm that the information provided in this affidavit is true and correct to the best of my knowledge and belief. I am willing to testify to the accuracy of this affidavit in a court of law if required.

Nursing Home Templates @ Template.net