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SAMPLE AFFIDAVIT
Affidavit of Birth of ____________________________________________________________________________________________.
[first, middle and LAST name of I-485 applicant]
I, ____________________________________________________________________________________, certify:
[first, middle and LAST name of person writing affidavit]
I am _______________________________________________’s ___________________________________________________________.
[name of I-485 applicant] [description of relationship to I-485 applicant,
i.e. biological mother, father, aunt, uncle, older sibling]
I was born on _______________________________________in ___________________________________________________________.
[month, date and year of birth] [town or province and country of birth]
I married _______________________________________________ on __________________ in _____________________________________.
[full name of spouse] [date of marriage] [place of marriage].
My spouse _____________________________________________ was born on __________________ in _______________________________.
[full name of spouse] [date of birth] [place of birth]
My spouse ____________________________________________ and I had a child named________________________________________________.
[name of spouse] [first, middle and LAST name of I-485 applicant]
* NOTE: If affidavits are being signed by someone other than the I-485 applicant’s parents, the affidavit must still list the full names of both of the
I-485 applicant’s parents.
_______________________________________________________ was born on _________________________ in __________________________.
[name of I-485 applicant] [month, date and year of birth] [town or province and country of birth]
___________________________________________ _____________was born at __________________________________________________.
[name of I-485 applicant] [place of birth, i.e. name of hospital, home]
located in __________________________________ at __________________ on ____________________________.
[town or province and country] [time of birth] [date of birth]
I know that ________________________________________________ was born on this date because ____________________________________
[name of I-485 applicant]
_______________________________________________________________________________________.
[explanation of how person writing affidavit knows of the birth of the I-485 applicant]
I currently reside at ______________________________________________________________________________________________________.
[address of person writing the affidavit].
I declare under penalty of perjury that the above is a true and correct statement.
______________________________________ ______________________________________
[name of person writing the affidavit] [signature of affiant]
Subscribed and sworn to before me on ________________________ in ____________________________________________________.
[date notary signs this document] [city and country where notary executed the affidavit]
_________________________________________
Notary [signature of notary]
Notary stamp
Affidavit of Birth
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