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Dependent Certificate Affidavit

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DEPENDENT CERTIFICATE AFFIDAVIT

I, __________, __________, resident of __________, holding __________, ordinarily resident within __________ (the "Deponent" or "I"), do hereby solemnly affirm and declare as follows:

1. THE SPONSOR

2. THE DEPENDANTS

3. PURPOSE

3.2 I undertake to inform the receiving office if any person named above ceases to be dependent, marries, starts earning, or dies, or if any other particular stated here changes, and I understand that the certificate may be withheld or cancelled if any statement made here is found false.

4. DECLARATION

4.1 Every statement made above is true to my own knowledge and belief, and I have concealed nothing material to this application. I am aware that making a false declaration in an affidavit is an offence.

VERIFICATION

DEPONENT

Signature: ______________________________
__________

ATTESTATION

Notary Public / Oath Commissioner
Registration No. and seal: ____________________

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