HomeMy WebLinkAboutAffidavit for Proof of Residency Form
AFFIDAVIT
State of Hawai’i }
}
County of Hawai’i }
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;
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
_______________________________________________
_____________________________ _________________
My commission expires: _____________________
Notary Printed Name Circuit
_____________________________ _________________
Notary Signature Date
(Stamp or Seal)
FORM: VRL-L (SID/DL) 401
REV. 10/01/2014