certify under penalty of perjury under U.S. law, that:
1. I was born on (Date [mm/dd/yyyy]) in (City) , (State) , (Country)
If you are not a U.S. citizen based on your birth in the United States, or a non-citizen U.S. national based on your birth in American Samoa (including
Swains Island), answer the following as appropriate:
a. If a U.S.citizen through naturalization, give Certificate of Naturalization number
b. If a U.S. citizen through parent(s) or marriage, give Certificate of Citizenship number
c. If U.S. citizenship was derived by some other method, attach a statement of explanation. d. If a Lawful Permanent Resident of the United States, give A-Number
e. If a lawfully admitted nonimmigrant, give Form I-94, Arrival-Departure Record, number
2. I am years of age and have resided in the United States since
3. This affidavit is executed on behalf of the following person:
(Date [mm/dd/yyyy])