On this date of _________________, I, (name of affiant) ,
residing at (street and number) (city) (state) (zip code)
BEING DULY SWORN DEPOSE AND SAY:
I was born on (date) at (city) (country)
I am a (country) citizen. My passport number is
I am a (current occupation) . I am employed by (company name and address)
I am currently single, have never been married (or was divorced/widowed on (date) and have never been remarried since that date).
Signature of the Affiant: _______________________________
Name in Print:________________________________________
(For the Notary Public)
Subscribed and sworn to before me by (name of affiant) on this____day of ________________.