AFFIDAVIT OF FACTS CONCERNING BIRTH I, ____________________, a citizen of _____________ and currently residing in __________ do hereby State that the

following is true and accurate to the best of my knowledge that: 1. I am the _________ of ___________ (Identify the Relationship, e.g. I am the Grandfather of Mr. Beneficiary) 2. I was born on __________ (List Affiants date of Birth. This will prove that the Affiant was an adult at the time that the event took place) in ____________ (list city, country) and I know of his/her birth because of my relationship to him/her. 3. In ______________ (Month/Year) I was living in ________________ (Town where Beneficiary was Born) 4. __________________(Beneficiary) was born on ___________________ in _________________ and I know of his/her birth because of my relationship to him/her. 5. ______________________(Beneficiary) was born to _____________________________(Fathers name) and _____________________ (Mothers name). Note: Choose either Number 6a or 6b below depending upon whichever is relevant to your case. 6a. I hereby attest to the fact that birth records for individuals born during this time are difficult if not impossible to obtain and that a birth certificate was not issued to ___________ (Beneficiary) on his/her birth. 6b. I hereby certify that the birth certificate for ______________(Beneficiary) does not mention his/her name because it was not customary at that time to include the childs name on the birth certificate.