I swear that I, ___________________________________ I am Single ________and I have never been married.  I was born on __________ & in ___________ in the ____________ in ________.
My fathers name is ______________________, My mother’s name is____________________
I am a citizen of _____________________.  

My passport #___________ was issued on _____________ in _______________, ________

We plan to get married in _______________________________

My Fiancé(e)'s ______________________________ and her nationality is ________________

Her Date of birth _____________________

Her fathers name is _________________________ her mother’s is______________________

And they reside at _________________________________________________________

Place of birth ____________________________________________________________

My e-mail address is ___________________________________

									_____________________________
									Affiant’s signature


State of New York ) 		  )ss.:County of _______ ) 
Sworn to before me this___________ day of __________, 20 ________, the undersigned
notary public, personally appeared___________________________________________
proved to me through satisfactory evidence of identification, which were _____________________,
to be the person(s) whose name is (are) signed on the preceding or attached document and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of (his) (her) (their) knowledge and belief.



___________________________________________________
                       (notarial signature and seal of notary)


My Commission Expires _____________________



This is a sample on how to fill out the form above form
        

I swear that I_____ Kenneth Smith Jr _________________ I am Single _ Male _ and I have 
(Your full name as shown in your passport) 				female/male
never been  married or I am currently divorced.  
I was born on _ December 31, 1992_ & in _Brooklyn _ in the _ New York _ in __ USA __
		date 			      city/town		        state/district 	           country

My fathers name is _ Smith, William_Jones __, My mother’s is___Wilson, Mary Ann __
         (last, first, middle name)				(maiden, first, middle name)

I am a citizen of _United State of America (USA) ________________. 
         (country)
My passport  #_0RY000G01A __ was issued on _2January 2009_ in _Philadelphia_, _USA_
         number 				date 			city/town 		country
We plan to get married in ___Ecuador, SA____________________
                (Country where the marriage will take place)
My Fiancé(e)'s _Theresa Santago __ and her nationality is _Ecuadorian ____________
 	full name
Her Date of birth __June 1, 1982________

Her fathers name is _ Santago, Joesph Rivera _  Her mother’s is__Sanchez, Carmen _
         (last name, first name, middle name)			(maiden, first, middle name)
And they reside at __12 Calle Jardines del Caribe, Ponce, PR 00715_____
         full address
Place of birth __San Juan ,Puerto Rico _
         (country)

My e-mail address is anonymous123@hotmail.com______________

------------------------- The notary fills out below this line -------------------------------------------

State of New York ) 		  )ss.:County of _______ ) 
Sworn to before me this___________ day of __________, 20 ________, the undersigned
notary public, personally appeared___________________________________________
					(name of the document signer(s)
proved to me through satisfactory evidence of identification, which were __________________________________,
							(Photo ID: Drivers License/Passport/Military ID)
to be the person(s) whose name is (are) signed on the preceding or attached document and who swore or affirmed to me that the contents of the document are truthful and accurate to the best of (his) (her) (their) knowledge and belief.



___________________________________________________   My Commission Expires _____________________

                       (notarial signature and seal/stamp of notary)					(date)



CERTIFICATE OF NON IMPEDIMENT