HomeMy WebLinkAboutAff for Proof of ResI_1aJ417_1Tj111111111
STATE OF HAWAII )
deposes and says: I am the [❑ father /mother ❑ spouse ❑ guardian ❑ other
SSN
(FULL LEGAL NAME OF APPLICANT)
being first duly sworn,
1 of
That this affidavit has been made in connection with the desire of Applicant to secure a state civil identification
card;
That the Applicant resides with Affiant and all documents for proof of principal residence address is under
Affiant's name.
That Affiant is submitting two (2) documents 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 FATHERMIOTHER /SPOUSE /GUARDIAN /OTHER
PRINTED NAME
IDENTIFICATION PRESENTED EXR DATE
SIGNATURE OF EXAXIINER DATE
FOR NOTARY USE ONLY:
Subscribed and sworn before me this day
of 120
Notary Public
State of
My connnission expires:
(Stamp or Seal)
FORM: VRL -L (SID) 401
REV. 01/03/2013
Judicial Circuit
NOTARY CERTIFICATION
(Hawaii Administrative Rules 5 -11 -8)
Document Date: No. Pages:
Document
Description:
Notary Printed Name Circuit
Notary Signature Date
(Stamp or Seal)