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SAMPLE AFFIDAVIT OF BIRTH
Preliminary Instructions:
-Please keep in mind that the Beneficiary is the
person whose birth is being proven (i.e. the person who has filed or will be
filing an I-485).
-The Affiant is the person who affirming that the birth did occur and is the
person who will be signing this document. The Affiant should have been an
adult (over 18 years of age) at the time that the event (e.g. Birth)
occurred.
-You should spell out all dates. You should never list the dates with just
numbers. For instance, you should list “March 1, 1970”, not 3-1-70 or
1-3-70.
-The Affidavit ought to be certified or notarized.
AFFIDAVIT OF __________________ (Affiant's Name)
I, ____________________, a citizen of _____________ and currently
residing in __________ do hereby
State that the following is true and accurate to the best of my knowledge:
1. I am the _________ of ___________ (Identify the Relationship, e.g. “I am
the Grandfather of Mr. Beneficiary”)
2. I was born on __________ (List Affiant's date of Birth. This will prove
that the Affiant was an adult at the time that the event took place) in
____________ (list city, country) and I know of his/her birth because of my
relationship to him/her.
3. In ______________ (Month/Year) I was living in ________________ (Town
where Beneficiary was Born)
4. __________________(Beneficiary) was born on ___________________ in
_________________ and I know of his/her birth because of my relationship to
him/her.
5. ______________________(Beneficiary) was born to
_____________________________(Father's
name) and _____________________ (Mother's name).
Note: Choose either Number 6a or 6b below depending upon whichever is
relevant to your case.
6a. I hereby attest to the fact that birth records for individuals born
during this time are difficult if not impossible to obtain and that a birth
certificate was not issued to ___________ (Beneficiary) on his/her birth.
6b. I hereby certify that the birth certificate for
______________(Beneficiary) does not mention his/her name because it was not
customary at that time to include the child's name on the birth certificate.
Dated: ________________________
__________________________________
(Affiant's Name)
Sworn to and signed before me this ____________ day of ____________,
_______________. (List Month and Year)
______________________________
Certifying Official/Notary Public
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