New Bern Towers - New Construction - MH: Affidavit Form

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New Bern Housing Authority
www.newbernha.org
Office Hours: Monday - Friday 8:00am - 5:00pm
Administrative Office: 252.633.0800
Mailing Address: PO Box 1486, New Bern, North Carolina 28563
Office Location: 1307 Tatum Drive, New Bern, North Carolina 28563

Fields marked with * must be completed or form will not submit.

Please NOTE - before completing this form. This form requires notarization by a Notary of Public.

Complete the form online & print. DO NOT submit this form online. Take the form to a Notary to be notarized.

After Notarization, drop off or mail the form to our office:
Housing Authority City of New Bern, North Carolina
PO Box 1486, New Bern, North Carolina 28563
1307 Tatum Drive, New Bern, North Carolina 28563

This is to affirm that I the Affiant listed below receive the listed amount below as a contribution towards the support of me and my family.

Name of Affiant

Payment Amount

Frequency of Payment*

Source of Contribution

I, Witness, to the best of my knowledge can truthfully say that the above family receives the amount stated above.

This statement is made in good faith.

I DO HEREBY SWEAR AND ATTEST THAT ALL OF THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.

WARNING: Title 18 Section 1001 of of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent statements to any department or agency of the united states.

For Notary Use Only

Witness

Date Witnessed

Affiant

Affiant Date

North Carolina County of Notary

Notary Public

Person 1 Appearing

Person 2 Appearing

These persons known to me or proved to me on the oath of ____ or through ____ to be the persons whose names are subscribed to the foregoing instrument and acknowledged to me that they executed the same for the purposes and consideration therein expressed.

My Commission Expires on

Notary Public State of North Carolina

Complete the form online & print. DO NOT submit this form online. Take the form to a Notary to be notarized. After Notarization, drop off or mail the form to our office: New Bern Housing Authority 1307 Tatum Drive, New Bern, NC 28563/PO Box 1486, New Bern, NC 28563