General Eligibility Affidavit Form

General Eligibility Affidavit Form

State or jurisdiction:    County:

Affiant Name:    Date of Birth:

Affiant Address:

Identification Type and Number:

Recitals

WHEREAS, the Affiant desires to declare under penalty of perjury the Affiant's eligibility status for purposes of eligibility determination, certification, enrollment, or receipt of benefits or services; and

WHEREAS, the Receiving Entity requires a sworn affidavit setting forth the Affiant's representations concerning identity, residency, age, and other eligibility criteria as a condition to further processing or issuance of benefits; and

WHEREAS, the parties intend that the statements contained herein be relied upon by the Receiving Entity for administrative, fiscal, and legal determinations;

NOW, THEREFORE, in consideration of the foregoing recitals and the mutual covenants contained herein, the Affiant hereby certifies, represents, and affirms as follows:

1. Definitions

For purposes of this Affidavit, the following definitions apply: "Affiant" means the person executing this affidavit; "Receiving Entity" means the organization, agency, or other recipient identified in the Notices section; "Eligibility Criteria" means the specific factual predicates that must be satisfied as described in Section 3 below.

2. Representations and Warranties of Affiant

The Affiant hereby represents and warrants to the Receiving Entity that the statements contained in this affidavit are true, complete, and correct to the best of the Affiant's knowledge and belief. Affiant acknowledges that false statements contained in a sworn affidavit may constitute perjury and may subject the Affiant to civil and criminal penalties under applicable law.

3. Eligibility Criteria — Affirmations (Check all that apply)

The Affiant affirms the following items by marking the applicable boxes. Each checked item constitutes a material representation made under oath.

I am a citizen or national of the United States or otherwise possess legal status authorizing participation.

I am a resident of the jurisdiction listed above and have resided at the address provided for the preceding six months unless an exception applies.

I meet the age requirement(s) applicable to the benefit or service for which I am applying.

I do not have any disqualifying criminal convictions or active prohibitions that would render me ineligible under applicable program rules.

I meet any additional eligibility requirements specific to the benefit or service as described by the Receiving Entity.

4. Affirmation Under Penalty of Perjury

I, the Affiant, declare under penalty of perjury under the laws of the jurisdiction named above that the foregoing is true and correct. I understand that making a false statement in this affidavit may subject me to prosecution for perjury and other civil or criminal penalties.

5. Recordkeeping and Verification

The Affiant authorizes the Receiving Entity and its authorized representatives to verify the representations herein by inspecting documents, requesting records from third parties, or otherwise conducting appropriate investigations. The Affiant will promptly provide copies of documentary evidence upon request.

6. Remedies and Indemnification

If any representation in this affidavit is found to be materially false, the Affiant shall be liable for any losses, damages, or costs incurred by the Receiving Entity arising from reliance on such representation, including reasonable attorneys' fees and administrative costs. Remedies available to the Receiving Entity are cumulative and in addition to any criminal penalties.

7. Notices

All notices required or permitted under this Affidavit must be delivered in writing to the Receiving Entity's contact information below or to the Affiant at the address above. Notices are deemed given upon personal delivery or three business days after deposit in the U.S. mail, postage prepaid.

8. Amendments; Waiver; Counterparts

This Affidavit may be amended only by a writing signed by both the Affiant and an authorized representative of the Receiving Entity. No failure or delay by either party to exercise any right or remedy constitutes a waiver of such right. This Affidavit may be executed in counterparts, each of which constitutes an original and all of which together constitute one and the same instrument.

9. Governing Law; Severability; Entire Agreement

This Affidavit shall be governed by and construed in accordance with the laws of the jurisdiction named above without regard to its conflicts of law principles. If any provision of this Affidavit is held to be invalid or unenforceable, the remaining provisions shall remain in full force and effect. This Affidavit constitutes the entire agreement between the Affiant and the Receiving Entity with respect to the subject matter herein and supersedes all prior oral or written statements or agreements.

10. Affirmation and Signature

I affirm that I have read and understand the contents of this Affidavit, that the statements made herein are true and accurate, and that I execute this Affidavit voluntarily for the purposes stated.

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