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:

1. I hereby declare that my current place of residence is [YOUR ADDRESS], Arizona.

2. This residence has been my home for [Length of Time at Current Address].

3. 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.

4. I intend to maintain the above address as my principal place of residence.

5. 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.

6. 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]

Affidavit Templates @ Template.net