AFFIDAVIT OF IDENTITY AND DISTINCTION
(Pursuant to La. R.S. 9:5501.1)
State of Louisiana
Parish of __________________
Before me, the undersigned authority, personally came and appeared:
_____________________________________________________, whose mailing address is
_____________________________________________________, and whose marital status is
______________, who after being duly sworn, deposed as follows:
I, ____________________________________, being of sound mind, acknowledge
and understand that any intentional falsification of information I am about to
provide shall subject me to penalties for the crime of injuring public records and
My full name is _____________________________________. I am ___ years old and
was born on the ____ day of ________________, 19 ___ in (city/parish/county and state
of birth): __________________________________________.
The last 4 digits of my social security number are ______.
I presently reside at __________________________________