Free Nursing Home Witness Affidavit Template
Nursing Home Witness Affidavit
I, [Your Full Name], residing at [Your Address] and reachable at [Your Number] and [Your Email], do hereby solemnly affirm and declare under penalty of perjury as follows:
I am writing this letter to provide a formal affidavit based on my firsthand experiences and observations which I had witnessed at a certain nursing home. Specifically, the nursing home that I am referring to is [Your Company Name] which is situated at [Your Company Address]. I want to formally put these experiences into record through this affidavit.
I am not affiliated with the nursing home in any official capacity. I am a concerned citizen who frequently visits residents at the facility.
I have been visiting [Your Company Name], located at [Your Company Address], regularly for the past [00] months. My visits primarily involve spending time with my [relation to the resident], [Resident's Name], who has been a resident at the facility for [00] months.
On [Date], at approximately [Time], during my visit to [Your Company Name], I observed the following incident: While in the dining hall, I witnessed a staff member, identified as [Staff Member's Name], speaking in a disrespectful and condescending manner to a resident, later identified as [Resident's Name]. Despite the resident's evident distress, the staff member continued their behavior without providing any assistance or de-escalation.
The incident occurred during lunchtime, a period of high activity in the dining hall. Several other residents and staff members were present, though it appeared that the staff member's behavior towards the resident went unnoticed or unaddressed by other staff members. The resident, [Resident's Name], is known to require additional support due to cognitive impairments, which may have contributed to their vulnerability in this situation. Additionally, the dining hall environment was particularly noisy and chaotic at the time, potentially exacerbating the resident's distress and the staff member's frustration.
I certify that the statements provided in this affidavit are true and accurate to the best of my knowledge and belief. I understand that providing false information in this affidavit may subject me to legal penalties.
On the provided date, which is [Date], and at the specified location, which is [Location], I have personally and willingly put my signature on this affidavit. No one has coerced or compelled me to do it; rather it has been signed entirely of my own accord and free will.
[Your Full Name]
Notary Acknowledgment:
State of [State], County of [County]
On this [Date], before me, a Notary Public in and for said County and State, personally appeared [Your Full Name], known to me to be the person whose name is subscribed to the foregoing instrument and acknowledged that [he/she] executed the same for the purposes therein contained.
Witness my hand and official seal.
[Notary Public Name]
[Notary Public Commission Number]
[Date]
