Fill and Sign the Affidavit Birth Form

Affidavit by Non-Parent to Prove Date of Birth of Child and Parentage to Social Security Administration in Order to Receive Benefits STATE OF _________________________________ COUNTY OF _______________________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, __________________________________________ (Name of Affiant) , who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. Affiant knows ________________________________________ (name of child) , and that such child was born on ____________________________________ (date) , at _______________________________________________________________________ ( name of hospital or other place of birth) , at ___________________________________ ________________________________________________________________________ ___________________________________ (street address, city, county, state, zip code) , because: (state how Affiant knows these facts) _________________________________ ________________________________________________________________________ _______________________________________________________________________ . 2. Affiant knows that the child's father is ___________________________________ (name of father) and that the child’s mother is __________________________________ (name of mother) , because: (state how Affiant knows these facts) _________________ _ ________________________________________________________________________ _______________________________________________________________________ . 3. The child is at present residing with (e.g., names of mother and father) _______________________________________________________________________, at ______________________________________________________________________ ___________________________________ (street address, city, county, state, zip code) . 4. This affidavit is a part of and attached to the (e.g., application for child disability benefits) _______________________________________________________________ _______________________________________________________________________. ____________________________________ ____________________________________ Printed Name & Signature of Non-Parent SWORN to and subscribed before me, this the ____________________________ ____________ (date) . ______________________________ NOTARY PUBLIC My Commission expires: ______________________