HomeMy WebLinkAboutResidency AffidavitFORM: VRL-L (SID/DL) 401
REV. 05/20/2014
AFFIDAVIT
)
STATE OF HAWAII )
)
being first duly sworn,
deposes and says: I am the [ father/mother spouse guardian other ] of
Date of Birth:
(FULL LEGAL NAME OF APPLICANT)
That this affidavit has been made in connection with the desire of Applicant to secure a state civil identification
card or driver’s license;
That the Applicant resides with Affiant and document(s) for proof of principal residence address is under
Affiant’s name.
That Affiant is submitting document(s) in support of proof of principal residence address as indicated under the
List of Acceptable Documents for Proof of Principal Residence Address displaying name and address of Affiant
and;
Further Affiant sayeth naught.
Dated:
________________________________________
SIGNATURE OF FATHER/MOTHER/SPOUSE/GUARDIAN/OTHER
PRINTED NAME
IDENTIFICATION PRESENTED EXP. DATE
________________________________________
SIGNATURE OF EXAMINER DATE
FOR NOTARY USE ONLY:
Subscribed and sworn before me this __________ day NOTARY CERTIFICATION
(Hawaii Administrative Rules 5-11-8)
of __________________________ , 20___________ .
Document Date:_____________No. Pages:________
____________________________________________
Notary Public
Document
Description:_________________________________
State of ___________________, _______Judicial Circuit ________________________ _________________
Notary Printed Name Circuit
My commission expires: ___________________________ ________________________ _________________
Notary Signature Date
(Stamp or Seal)
(Stamp or Seal)