Free Nursing Home Affidavit Template
Nursing Home Affidavit
I, [Full Name of Affiant], being of sound mind and acting under oath, hereby declare the following information to be true and accurate to the best of my knowledge and belief.
Identification of Affiant
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Name: [Full Name of Affiant]
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Date of Birth: [Date of Birth]
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Current Address: [Current Address, if different]
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Relationship to Resident: [e.g., Spouse, Daughter, Legal Guardian]
Identification of Nursing Home
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Name: [Your Company Name]
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Address: [Your Company Address]
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Contact Information: [Your Company Number], [Your Company Email]
Confirmation of Residency
I, [Full Name of Affiant], hereby confirm that my mother, [Name], has been a resident of [Your Company Name] from [Date], to the present date, [Date]. During this period, she has received continuous care and assistance from the staff at [Your Company Name].
Witness Statement
I declare that I have signed this affidavit in the presence of [Witness's Name], who is not related to me by blood or marriage and who has no financial interest in the matter.
Notarization
Signed under oath by:
[Full Name of Affiant]
[Date]
State of [Your State], County of [Your County]
On this [Date], before me, the undersigned notary public, personally appeared [Full Name of Affiant], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he executed the same for the purposes therein contained.
Notary Public, [State]
My Commission Expires: [Expiration Date]
Legal Disclaimer
I comprehend that if I make a false statement in this affidavit, it is treated as perjury. This means that I am completely aware that providing incorrect or misleading information is against the law and could potentially lead to legal consequences or punishment that may be enforced against me.
Contact Information:
[Full Name of Affiant]
[Affiant's Number]
[Affiant's Email]
I affirm that the information provided in this affidavit is true and correct to the best of my knowledge and belief. I am willing to testify to the accuracy of this affidavit in a court of law if required.
