Sample Affidavit of Birth by Mother

A petition for Permanent Residency in the US requires proof of birth. IS the petitioner is unable to furnish one, an affidavit of birth is submitted in lieu. The Affidavit must be submitted in conjunction with other birth records. An Affidavit of Birth (Mother) will include your full name, birth date, and place of birth along with the details of your mother’s full name, birth date, birthplace.

Affidavit of Birth by Mother

I, [your mother’s full name], being duly sworn, hereby affirm and state under oath that:

  1. I live at [your mother’s complete address].
  2. I was born in [your mother’s birth city/town, state/province and country] on [your mother’s birth date], and I am the mother of [your full name].
  3. I am married to [your father’s complete name]. We have been married since [marriage date].
  4. [Your full name] was born on [your birth date], to me and my spouse, [your father’s name]. [your full name] was born in [your birth city/town, state/province and country].
  5. I gave birth to [your full name] and I am giving this sworn statement because no birth certificate/record exists for my [daughter/son] following numerous unsuccessful attempts by my husband and I at locating a birth certificate for our child.
  6. I solemnly swear (affirm) that the above statement is true and correct to the best of my knowledge and belief. I understand giving false testimony under oath in connection with an immigration application is a federal criminal offense that can attract severe terms of imprisonment (18 U.S.C. § 154).

__[Print your mother’s full name]__                        ______[Date]______


___[Mother’s Signature]____

Verification of a Statement on Oath or Affirmation


State of _____________________________________________

County of ___________________________________________

Subscribed and Sworn to (affirmed) before me this _______   day of ________    , 20_______

by ____________________________ (name(s) of individual(s) making statement, personally appeared before me in _______[insert state]______, proved to me on the basis of satisfactory evidence to be the person (s) whose name is subscribed to the within Affidavit and acknowledged to me that he/she executed the same in his/her authorized authority, and who being first duly sworn on oath according to law, deposes and says that he/she has read the foregoing Affidavit subscribed by him/her, and that the matters stated herein are true to the best of his/her information, knowledge, and belief.

I certify under PENALTY OF PERJURY under the laws of the state of _________________ that foregoing paragraph is true and correct.

Identifying Document Submitted:

Type: ____________________________________________________

Date of Issuance/Expiration: __________________________________

Document Number: _________________________________________


WITNESS my hand and official seal

__________________________________   (Notary Seal)

Signature of Notarial Officer

My commission expires: _________________________________

The sample documents provided here are for informational purposes only and to be utilized at the user’s discretion. These act as a guide only and the content within these are to be customized as per requirement. While Lawbench covers general guidelines, it does not guarantee access to visas or ensure entry into the United States of America or assure any other form of privileges. Lawbench and its affiliates are not responsible for any losses or damages that may arise from having used these sample documents.