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I_1aJ417_1Tj111111 <br />STATE OF HAWAII ) <br />being first duly sworn, <br />deposes and says: I am the [❑ guardian ❑ custodian ❑ have control/maintenance] of <br />SSN <br />(FULL LEGAL NAME OF INCOMPETENT INDIVIDUAL) <br />That this affidavit has been made in connection with the desire of Affiant to secure a state civil identification <br />card on behalf of the incompetent individual; <br />That Affiant is submitting two (2) documents in support of proof of principal residence address as indicated <br />under the List of Acceptable Documents for Proof of Principal Residence Address displaying name and address <br />of Affiant and; <br />Further Affiant sayeth naught. <br />Dated: <br />PRINTED NAME <br />IDENTIFICATION PRESENTED EXR DATE <br />SIGNATURE OF EXAXIINER DATE <br />FOR NOTARY USE ONLY: <br />Subscribed and sworn before my this day <br />of 120 <br />Notary Public <br />State of <br />My commission expires: <br />Judicial Circuit <br />NOTARY CERTIFICATION <br />(Hawaii Administrative Rules 5 -11 -8) <br />Document Date: No. Pages: <br />Document <br />Description: <br />Notary Printed Name Circuit <br />Notary Signature Date <br />(Stamp or Seal) <br />(Stamp or Seal) <br />