I, _______________________, hereby depose
and say that I am personally in need of financial assistance in the amount of
$________, and that the facts and information set forth herein are true and
correct to the best of my knowledge, and belief and that I take this Affidavit
pursuant to the penalties of 18 PA C. S. S 4904 relating to unsworn
falsification to authorities:
1. My name, address, phone number, and e-mail address are as follows:
(All information must be supplied)
__________________________
__________________________
__________________________
__________________________
2. I am personally familiar with the witness(es) who have completed exhibit (s)
A, (# of exhibit A's attached ___) having known me the Applicant for at least
___ years and ____ months.
3. I have read the Affidavits for Verification and I believe that the
statements made by the witnesses therein are true and correct.
4. I the Applicant, _____________, is known to be honest, of good character
and competence.
5. ___ I am related by blood ___ or by marriage __ to the Witness (es)
_________________________________________________________.
6. The purpose for my request to receive $_________ in Financial Assistance,
is to cover the cost of
_______________________________________________________________
_______________________________________________________________.
This financial need occurred when I was
_______________________________________________________________.