Indiana Affidavit of Residency
This document serves as a sworn affidavit for establishing residency within the state of Indiana, in accordance with relevant state guidelines and statutes. It is intended to be a declaration of one's residential status for various legal, educational, and personal purposes. By completing this affidavit, the signer attests under penalty of perjury that the information provided is accurate and truthful.
PERSONAL INFORMATION
Full Legal Name: _______________________________________________
Date of Birth: ____________________ (MM/DD/YYYY)
Indiana Driver's License or State ID Number: ___________________________
RESIDENCY INFORMATION
Current Indiana Home Address: ___________________________________________
City: _______________________, IN
Zip Code: ______________
Date Residency at Current Address Began: ____________________ (MM/DD/YYYY)
ADDITIONAL INFORMATION
If applicable, provide details of any previous Indiana residence below:
Previous Indiana Home Address: __________________________________________
City: _______________________, IN
Zip Code: ______________
Date Residency at Previous Address Began: __________________ (MM/DD/YYYY)
Date Residency at Previous Address Ended: __________________ (MM/DD/YYYY)
DECLARATION AND SIGNATURE
I, the undersigned, declare under penalty of perjury under the laws of the State of Indiana that the foregoing is true and correct. I understand that any false statement made within this affidavit may subject me to penalties under the law. This affidavit is executed voluntarily for the purpose of establishing my Indiana residency.
Date: ____________________ (MM/DD/YYYY)
Signature: ________________________________________
NOTARY PUBLIC (If applicable)
This section to be completed by a Notary Public if required by the requesting agency or for added legal affirmation.
State of Indiana )
County of ________ )
Subscribed and sworn to (or affirmed) before me on this ___ day of ___________, 20__, by _________________________________, proved to me on the basis of satisfactory evidence to be the person who appeared before me.
Notary Public Signature: ________________________________
Printed Name: ______________________________________
My Commission Expires: ________________