On this date of
_________________, I, (name of affiant) ,
residing at (street and
number) (city) (state) (zip code)
BEING DULY SWORN DEPOSE AND
SAY:
I was born on (date)
at (city) (country)
I am a (country)
citizen. My passport number is
I am a (current
occupation) . I am employed by (company name and address)
I am currently single, have never
been married (or was divorced/widowed on (date) and have never
been remarried since that date).
Signature of the Affiant:
_______________________________
Name in
Print:________________________________________
(For the Notary Public)
Subscribed and sworn to before me by (name of affiant) on this____day of ________________.