Arizona Affidavit of Residence
Arizona Affidavit of Residence
State of Arizona
County of [County Name]
Introduction:
I, [YOUR NAME], being duly sworn, declare and affirm under penalty of perjury that the following statements are true and correct to the best of my knowledge:
Statement of Facts:
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I hereby declare that my current place of residence is [YOUR ADDRESS], Arizona.
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This residence has been my home for [Length of Time at Current Address].
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I affirm that the information provided herein regarding my address and the duration of my residency is accurate and true to the best of my knowledge.
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I intend to maintain the above address as my principal place of residence.
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This affidavit is provided for the purpose of establishing my eligibility for state-run medical assistance programs based on my residency in the State of Arizona.
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It serves as documentation to verify my residency status as required by the program's eligibility criteria.
Additional Information (if applicable):
I certify that I reside at the address provided and that [Names of Dependents, if applicable] also reside with me at this address.
Declaration:
I understand that providing false information on this affidavit can result in penalties under the law. I hereby authorize the release of this information for the purpose of verification of my Arizona residency status.
Signature:
[YOUR NAME]
Subscribed and sworn to (or affirmed) before me on this [Day] of [Month], [Year], by [YOUR NAME].
[NOTARY PUBLIC NAME]
