SEPARATION AFFIDAVIT

OF

Your names
We do hereby certify under the penalties of perjury:

That we are eighteen years of age or older, have personal knowledge to testify to the matters stated herein, and are
competent to bear witness under oath.

That prior to _______________ mm/dd/yy, we were living as husband and wife at

_______________________________________________________________________________________________

That on or around _________________mm/dd/yy, we agreed to live separate and apart and to establish separate legal
residences, but as of this date, there is no formal written document which memorializes our separation.

That since ________________ mm/dd/yy, _____________________________________ (Husband) has resided at

_________________________________________________________ Maryland and voting, driving and income tax
records bear this out.
That since ________________ mm/dd/yy, ______________________________________ (Wife) has resided at
_________________________________________________________Maryland and voting, driving and income tax
records bear this out.
That since ________________mm/dd/yy, we have, in fact, lived separated and apart without interruption. That there is
no present likelihood of either of us returning to the residence of the other and there is no reasonable expectation of
reconciliation.

That we acknowledge that if we fail to maintain separate residences, any Homestead Tax Credit that may be granted to
both residences will be removed as of the first day of the taxable year in which the discovery is made.

That until a final divorce. decree is provided, we agree to provide, upon request from SDAT, documentation that the
separate residences have been maintained.

That our legal separation and maintenance of separate residences is not for the purpose of tax avoidance.

We do solemnly affirm under the penalties of perjury the contents of the foregoing are true based on our personal
knowledge.
______________________________________________
Husband
______________________________________________
Wife

IN THE STATE OF MARYLAND, (____________________________________________COUNTY/CITY)

I HEREBY CERTIFY that on this ______ day of _______________________ 20____, before me, the subscriber, a
Notary Public, in and for the City and State aforesaid, personally appeared , who made oath in due form of law that the
information contained in this Affidavit is accurate based on their personal knowledge.

AS WITNESS my hand and Notarial Seal. ______________________________________________

My Commission expires: _____________________________