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I_1aJ417_1Tj111111111 <br />STATE OF HAWAII ) <br />being first duly sworn, <br />deposes and says: ❑ I am the [❑ father ❑ mother ❑ guardian] of <br />born on <br />(FULL LEGAL NAME OF CHILD) (DATE OF BIRTH OF CHILD) <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 minor child; <br />That the minor child is at least 10 years of age and under the age of fourteen (14) and requires Affiant's <br />signature; <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 FATHER/AIOTHER/GUARDIAN <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 />(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 />