PROBATE COURT OF SHELBY COUNTY, OHIO IN THE MATTER OF CASE NO. AFFIDAVIT STATE OF COUNTY OF being first duly cautioned and sworn, deposes and says that he/she [check one of the following]: Was the attending physician at the birth of the (applicant) (minor child of the applicant) and the statements in the Application to Correct Birth Record are true. Has personal knowledge that the facts stated in the Application to Correct Birth Record are true. Affiant has known the (applicant) (minor child of the applicant) for years, and the affiant's relationship to (applicant) (minor child of the applicant) is that of a(n) Affiant Sworn to before me and subscribed in my presence this day of , . Notary Public American LegalNet, Inc. www.FormsWorkFlow.com H.C. FORM 623.03 - AFFIDAVIT 02/10/03