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STATE OF ----------)
) s.s.:
COUNTY OF ---------)
[Name] (Affiant), being duly sworn, deposes and says:
1. That Affiant is the [relationship] of the minor child [name].
2. That Affiant is well acquainted with the child and states that to the best of Affiant's knowledge the child was born on or about [date], and is now [number] years of age.
[signature]
Affiant
*** If Required By FederaL or State Law ***
This Section for Notary:
ACKNOWLEDGMENT
State of _________
County of ________ [COUNTY]
On [DATE] before me, [NAME OF NOTARY], notary, personally appeared [NAME OF PERSON(S) INVOLVED], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
Witness my hand and official seal.
Signature ________
Notary
My commission expires: _____
(Seal)