STATE OF ____________________
COUNTY OF ____________________
I/We, ____________________, born in ____________________, in the county of ____________________ in the state of ____________________ and being duly sworn, do hereby depose and attest that:
1. My full and legal name is ____________________
2. My current address is ____________________
3. My Social Security number ____________________
4. As proof of identity, I have presented the public notary the following photo ID: ____________________
5. I understand that the purpose of this document is to demonstrate that I am the proven client of ____________________
6. I understand that the falsification of this document is a felony offense, and I swear that all of the aforementioned information is true.
____________________
AFFIANT
Subscribed and sworn to before me this ____________________ day of ____________________ 20 ____________________
____________________
(Notary Public),
____________________ County.
My commission expires ____________________ 20 ____________________