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I_1aJ417_1Tj111111111 <br />STATE OF HAWAII ) <br />deposes and says: I am the [❑ father /mother ❑ spouse ❑ guardian ❑ other <br />SSN <br />(FULL LEGAL NAME OF APPLICANT) <br />being first duly sworn, <br />1 of <br />That this affidavit has been made in connection with the desire of Applicant to secure a state civil identification <br />card; <br />That the Applicant resides with Affiant and all documents for proof of principal residence address is under <br />Affiant's name. <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 />SIGNATURE OF FATHERMIOTHER /SPOUSE /GUARDIAN /OTHER <br />PRINTED NAME <br />IDENTIFICATION PRESENTED EXR DATE <br />SIGNATURE OF EXAXIINER DATE <br />FOR NOTARY USE ONLY: <br />Subscribed and sworn before me this day <br />of 120 <br />Notary Public <br />State of <br />My connnission expires: <br />(Stamp or Seal) <br />FORM: VRL -L (SID) 401 <br />REV. 01/03/2013 <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 />