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Hawaii Affidavit for Proof of Residence Form

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Hawaii Affidavit for Proof of Residence Form
Hawaii Affidavit for Proof of Residence Form
CS-L(DL)242 (05-2014)
AFFIDAVIT
)
STATE OF HAWAII )
)
being first duly sworn,
deposes and says: I am the [
father/mother spouse guardian other _____________________] of
SSN
(FULL LEGAL NAME OF APPLICANT)
That this affidavit has been made in connection with the desire of Applicant to secure a state civil identification
card or driver license;
That the Applicant resides with Affiant and documents for proof of principal residence address is under Affiant’s
name.
That Affiant is submitting the number of required documents in support of proof of principal residence address
as indicated under the List of Acceptable Documents for Proof of Principal Residence Address displaying name
and Hawaii address of Affiant and;
Further Affiant sayeth naught.
Dated:
________________________________________
SIGNATURE OF FATHER/MOTHER/SPOUSE/GUARDIAN/OTHER
PRINTED NAME
IDENTIFICATION PRESENTED EXP. DATE
________________________________________
SIGNATURE OF EXAMINER DATE
FOR NOTARY USE ONLY:
Subscribed and sworn before me this __________ day NOTARY CERTIFICATION
(Hawaii Administrative Rules 5-11-8)
of __________________________ , 20___________ .
Document Date:_____________No. Pages:________
____________________________________________
Notary Public
Document
Description:_________________________________
State of ___________________, _______Judicial Circuit ________________________ _________________
Notary Printed Name Circuit
My commission expires: ___________________________ ________________________ _________________
Notary Signature Date
(Stamp or Seal)
(Stamp or Seal)
Hawaii Affidavit for Proof of Residence Form