AFFIDAVIT

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KINGDOM OF THE NETHERLANDS
PROVINCE OF NORTH HOLLAND
CITY OF AMSTERDAM SS:
CONSULATE GENERAL OF THE
UNITED STATES OF AMERICA

Before me,

Consular Officer of the United States of America in and for the district of Amsterdam,
the Netherlands, duly commissioned and qualified, personally appeared:

who, being duly sworn, deposes and says as follows:

My full and correct name is

and I was born in , on
My current residence is

I am a citizen of , bearer of passport# , issued at/by

, on , expiring on ,

which serves as proof of my identity and citizenship.

Married 
My marital status is: Divorced 
(tick appropriate box ) Widowed 
Never Married 
My father's full name is
My mother's full name is
IN WITNESS WHEREOF I have hereunto set my hand on .

(Signature)
SUBSCRIBED AND SWORN/AFFIRMED TO before me, the undersigned Consular officer of the
United States of America at Amsterdam, the Netherlands, on .

THE CONSULATE GENERAL ASSUMES NO RESPONSIBILITY FOR THE ACCURACY OF THE STATEMENT MADE BY THE AFFIANT.
For use in the Netherlands only: Article 1(d)(a) of the 1961 The Hague Convention Abolishing the Requirement of Legalization for
Foreign Public Documents exempts "documents executed by diplomatic or consular agents" from Apostille requirement

Affidavit of Civil Status