AFFIDAVIT

I, ______, aged ______ years, son / daughter / spouse of ______, do hereby solemnly affirm and state on oath as follows:

Purpose

This affidavit is made as a general declaration.

Statement

______

Verification

I, the deponent, solemnly affirm that the contents of this affidavit are true and correct to the best of my knowledge and belief, and nothing material has been concealed or falsified.

Place: ______

Date: ______

Deponent: ______

Attestation by Notary / Oath Commissioner