AFFIDAVIT OF VERIFICATION

 

In RE:____________________:

 

AFFIDAVIT STATEMENT

 

I,________________________, hereby depose and say that I am personally familiar with the Applicant, ____________________, and that the facts set forth herein in this Affidavit Exhibit A and the attached statement from Applicant stating the reason for their request to receive financial assistance 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 Applicant, ________________________, having known the Applicant for at least ______ years & _____ months.

3.I have read the request for financial Assistance made by the applicant and I believe that the statements made therein are true and correct.

4. I find the Applicant, ______________________, to be honest, of good character and competence.

5. __ I am related by __ blood or __ marriage to the Applicant, (check & state how) _____________________________________________________________________. 

 OR

6. __I am not related by blood or marriage to the Applicant. 

 

            

 

SWORN TO AND SUBSCRIBED 

BEFORE ME THIS_______DAY OF      

________________, 200_       

 

                                Respectfully submitted,

                                _______________________
                                (Print Name)

                                _______________________
                                (Signature)

 

NOTARY PUBLIC          

 

 

 

 

 

Exhibit A