Fill and Sign the Affidavit Birth Form 497329860

Affidavit by Attending Physician 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 resides at ____________________________________________________ ________________________________________________________________________ ___________________________________ (street address, city, county, state, zip code) , and has continuously been a physician licensed to practice medicine in __________________________________ (name of state) for _____________________ (period of time) . Affiant is now engaged in the active practice of medicine at ________________________________________________________________________ ________________________________________________________________________ ___________________________________ (street address, city, county, state, zip code) . 2. Affiant knows ________________________________________ (name of child) , because Affiant was the attending physician when said child was born on __________________________________________ ( date) , at _____________________ ___________________________________ ( name of hospital or other place of birth) , at ________________________________________________________________________ ________________________________________________________________________ __________________________________ (street address, city, county, state, zip code) . 3. The child is at present residing at ______________________________________ ________________________________________________________________________ ___________________________________ (street address, city, county, state, zip code) . 4. 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) _________________ ________________________________________________________________________ _______________________________________________________________________ . 5. This affidavit is a part of and attached to the (e.g., application for child disability benefits) _______________________________________________________________ _______________________________________________________________________. ____________________________________ ____________________________________ Printed Name and Signature of Physician SWORN to and subscribed before me, this the ____________________________ _________________ (date). ____________________________________ NOTARY PUBLIC My Commission expires: ______________________