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 for Registration of Birth are true. NOTE: If the affidavit of the attending physician cannot be secured, the application must be supported by the affidavits of two (2) persons, relative or non-relative, having personal knowledge of the facts. ___ Has personal knowledge that the facts stated in the Application for Registration of Birth 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 H.C. FORM 624.03 - AFFIDAVIT American LegalNet, Inc. www.FormsWorkFlow.com