Affidavit

One and the Same Person

I,__[insert name]______________ , of ___[insert place origin]________, born on __[insert

birthdate]______, solemnly declare that I am the same individual as stated in the following
documents:

1. List the names used and the type of document

I make this Affidavit to declare the inconsistencies with the names indicated on my documents.
AND I make this solemn declaration, conscientiously believing it to be true and knowing that it
is of the same force and effect as if made under oath. I understand giving false testimony under
oath in connection with an immigration application is a federal criminal offense that can attract
severe terms of imprisonment (18 U.S.C. § 154).

_______________________________ _______________________

Signature of Deponent Date

Verification of a Statement on Oath or Affirmation

1
State of _____________________________________________

County of ___________________________________________

Subscribed and Sworn to (affirmed) before me this _______ day of ________ , 20_______

by ____________________________ (name(s) of individual(s) making statement, personally

appeared before me in __[insert state]_____________, proved to me on the basis of satisfactory
evidence to be the person (s) whose name is subscribed to the within Affidavit and
acknowledged to me that he/she executed the same in his/her authorized authority, and who
being first duly sworn on oath according to law, deposes and says that he/she has read the
foregoing Affidavit subscribed by him/her, and that the matters stated herein are true to the best
of his/her information, knowledge, and belief.

I certify under PENALTY OF PERJURY under the laws of the state of _________________
that foregoing paragraph is true and correct.

Identifying Document Submitted:

Type: ____________________________________________________
Date of Issuance/Expiration: __________________________________
Document Number: _________________________________________

WITNESS my hand and official seal

__________________________________ (Notary Seal)

Signature of Notarial Officer

My commission expires: _________________________________