Kentucky Affidavit of Birth

State of Kentucky

County of [COUNTY]

Introduction:

I, [YOUR NAME], being duly sworn, depose and say:

Statement of Facts:

The undersigned affiant, [YOUR NAME], residing at [YOUR ADDRESS] and reachable at [YOUR TELEPHONE NUMBER], hereby affirms their relationship to the registrant as the mother, providing valid identification and supporting documentation as required by the relevant authorities.
This affirmation is made in accordance with legal requirements to obtain the birth record of the registrant.
The subject of this affidavit, [Full Name of the Person at Birth], was born on [Month], [Day], [Year], in [City/County, State, Hospital].
At the time of the registrant's birth, the parent(s) were listed as [Full Name(s) of Parent(s) at the Time of Birth].
This statement is made to assert the accuracy of the birth record in question and to verify my relationship and proximity to the events described.

Circumstance of Affidavit:

This affidavit is made in support of obtaining a replacement for the lost birth certificate of the above-named registrant. I hereby affirm that the original birth certificate for the registrant has been lost, and no other form of official birth record for the registrant is available to me/us.

Affirmation of Truth:

I affirm that the information provided in this affidavit is true and correct to the best of my knowledge and belief. I understand that providing false statements in this affidavit is subject to penalties for perjury.

Reason for Replacement Request:

Describe the reason for the lost birth certificate and any efforts made to locate the original document. Include details, if applicable, about why the replacement is necessary (e.g., for obtaining a passport, driver's license).

Signature and Notarization:

IN WITNESS WHEREOF, I have hereunto set my hand this [DAY], of [MONTH], [YEAR].

[YOUR NAME]

Subscribed and sworn to before me this [DAY], of [MONTH], [YEAR] , by [YOUR NAME], who is personally known to me or has produced government-issued identification, such as a driver's license or passport, as identification.

[Notary Public's Signature]