Affidavit of Birth Certificate

I, , of

bearing identification (if any):

hereby solemnly affirm and declare as under:

1. That I am the parent/legal guardian of

2. That the date of birth of the said person is

3. Place of birth:

4. Relationship to child/person:

5. Reason affidavit is required:

I affirm that the above statements are true to the best of my knowledge and belief.

Date:

Signature

Name of Deponent