AFFIDAVIT OF SINGLE STATUS

On this date of _____________________________, 2011, I, the undersigned,

Full Name (Nombre): 

Male (Masculino) or Female (Femenino):

Date of Birth (Fecha de Nacimiento):

Place of Birth (Lugar de Nacimiento):

Social Security Number (Numero de Seguro Social):

US Passport No (Numero de Pasaporte):

Current Occupation (Ocupacion Actual):

Employer (Empleador):
			        
Permanent Address (Direccion Permanente):

Being duly sworn in, hereby solemnly declare that, under the law of the United States, I am currently single, have never been married or am legally divorced, and fully qualified to marry the following Peruvian citizen:

Full Name (Nombre):

Male (Masculino) or Female (Femenino):

Date of Birth (Fecha de Nacimiento):

Place of Birth (Lugar de Nacimiento):

Identified by DNI card number (Documento Nacional de Identidad):

Permanent Address (Direccion Permanente): 

I declare that the statements made in this affidavit are true and correct and I take full responsibility for them under the US law of perjury. I also declare that I shall marry the above-named person according to the law of Perú.

Signature of the Affiant:

Full Name in Print:



For the Notary Public:
Sworn to and subscribed before me on this _____ day of _____________, 2011