Notarized Sworn Statement

NOTARIZED SWORN STATEMENT OF THE CLAIMANT
Claim Number _________________
After being duly sworn, the affiant states as follows:
1.
My full name is ___________________________________.
2.
My current address is ____________________________________________
Street Address
______________________________________________________________
City
County
State ZIP Code
3.
My date of birth is: month ___________________, date_________, year____________
___________________________
Signature of Affiant
STATE OF
COUNTY OF
)
)
Sworn to and subscribed before me this_________ , day of
___________, _____, by _________________________________.
(Month)
(Year)
(Name of person making statement)
__________________________________
(Signature of Notary Public)
_________________________________________________________
(Print, Type, or Stamp Commissioned Name of Notary Public)
______________________________________________________________
Address of Notary
______________________________________________________________
City
County
State ZIP Code
*Notary must identify the type of government issued photographic identification produced that
verifies Affiant’s name and date of birth as stated on this form above.
Type of identification shown to Notary by Affiant (such as a drivers license, state
identification card, passport, or other similar valid government issued photographic
identification): ________________________________
* Pursuant to Section 717.124(1), FS, the claimant must produce to the notary photographic
identification of the claimant issued by the United States, a state or territory of the United States, a
foreign nation, or a political subdivision or agency thereof.
Form DFS-A4-2007, Effective 10-13-10, incorporated into Rule 69I-20.0022, F.A.C.

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