AFFIDAVIT OF OWNERSHIP
State of NEW YORK}
} SS
County of KINGS}
RE: Birth Certificate, Birth No 199-72-309290, Authenticated B.C. No 16292249
I, OWN THE BC the undersigned, first lien holder, beneficial owner, having obtained the age of majority,
depose and state that I am familiar *purchase this template for exact and true affidavit wording*
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Printed name
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Signature
Signed and sworn to before me this ________ day Of February, 2017.
I, __________________________________ A Notary, attest, the person signing this document is also
the person whose image appears above.
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________________________________ Notary Public My Commission Expires