On this date of_________________, I,(name of affiant),residing at(street and number)(city)(state)(zip code)
BEING DULY SWORN DEPOSE AND SAY:
I was born on(date)at(city)(country)
I am a(country)citizen. My passport number is
I am a(current occupation). I am employed by(company name and address)
I am currently single, have never been married (or was divorced/widowed on(date)and have never been remarried since that date).
I have no direct blood tie or kinship within 3 generations with XXX(name of fiancee/fiance).
Signature of the Affiant: ____________________
Name in Print: ____________________________
(For the Notary Public)
Subscribed and sworn to before me by(name of affiant)on this____day of ________________.