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Affidavit of Single Status

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Full Legal Name *Date of Birth *Place of Birth — City *Place of Birth — Country *Place of Birth — State/Province *

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Affidavit of Single Status

I, [Full Legal Name], being of legal age and being duly sworn, do hereby declare and affirm under penalty of perjury the following:

1. I was born on [Date of Birth] in [Place of Birth].

2. I am a citizen of [Country] and bearer of passport No. [Passport Number].

3. My current address is [Current Address].

4. My civil state is [Civil Status], and currently there is no legal impediment preventing my marriage.

5. I intend to marry [Intended Spouse Name], who is resident of [Residence].

Signature

Date

COMMONWEALTH OF PENNSYLVANIA

COUNTY OF PHILADELPHIA

Sworn to (or affirmed) and subscribed before me by means of ☐ physical presence or ☐ online notarization, this _______ day of __________________, __________, by [Full Legal Name].

Signature of Notary Public

(Seal)