AFFIDAVIT OF BIRTH

State of Alabama

I, ________, residing at the following address: ________, do certify under the penalty of perjury that I was born on ________ in ________.

This affidavit is executed on behalf of the following individual:

Name: ________
Gender: Male
Age: ________ years old
Current Address: ________
Citizenship: ________
Marital Status: Single

I have known ________ since ________. I further declare that ________ was born on ________ to ________.

I have direct personal knowledge of the event and circumstances concerning the birth of ________ for the following reason:

________

This Affidavit of Birth is being submitted for the following reason:

________

Oath or Affirmation of Affiant:

I certify under penalty of perjury under Alabama law that I know the contents of this Affidavit signed by me and that the statements are true and correct to the best of my knowledge.

______________________________
________, Affiant

______________________________
Date

STATE OF ______________________, COUNTY OF ______________________:

On this ________ day of __________________________, __________, before me,

____________________________, personally appeared ________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that they executed the same as for the purposes therein contained.

In witness whereof I hereunto set my hand and official seal.

______________________________
Notary Public

________________________
Title

My commission expires: _________________