Affidavit

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Housing Authority of South Bend
Phone: 574.235.9346 • Fax: 574.544.5165
501 Alonzo Watson Dr. • South Bend, IN 46601
Monday-Thursday 8:30 am-5:30 pm (Closed Fridays)

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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 of South Bend
501 Alonzo Watson Drive
South Bend, IN 46601

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

[{"type":"paragraph","subtype":"p","label":"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.","className":"d-block"},{"type":"text","required":true,"label":"Name of Affiant","name":"affiant","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","required":true,"label":"Payment Amount","placeholder":"$","name":"payment-amount","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"select","required":true,"label":"Frequency of Payment","name":"payment-frequency","className":"col-md-6 col-lg-3","values":[{"label":"Please Select One","value":"no-option-selected","selected":true},{"label":"Per Month","value":"per-month"},{"label":"Per Week","value":"per-week"}]},{"type":"text","label":"Source of Contribution","name":"source-of-contribution","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"text","label":"I, Witness, to the best of my knowledge can truthfully say that the above family receives the amount stated above.","name":"witness","className":"d-block","subtype":"text"},{"type":"paragraph","subtype":"p","label":"This statement is made in good faith.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"I DO HEREBY SWEAR AND ATTEST THAT ALL OF THE INFORMATION ABOVE IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"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.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"For Notary Use Only","className":"d-block"},{"type":"text","label":"Witness","name":"witnessed","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"date","label":"Date Witnessed","name":"date-witnessed","className":"col-md-6 col-lg-3"},{"type":"text","label":"Affiant","name":"affiant","className":"col-md-6 col-lg-3","subtype":"text"},{"type":"date","label":"Affiant Date","name":"affiant-date","className":"col-md-6 col-lg-3"},{"type":"text","label":"Indiana County of Notary","name":"In-county-of-notary","className":"col-md-6","subtype":"text"},{"type":"text","label":"Notary Public","name":"notary","className":"col-md-6","subtype":"text"},{"type":"text","label":"Person 1 Appearing","name":"person-1-appearing","className":"col-md-6","subtype":"text"},{"type":"text","label":"Person 2 Appearing","name":"person-2-appearing","className":"col-md-6","subtype":"text"},{"type":"text","label":"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.","name":"persons-known-by","className":"d-block","subtype":"text"},{"type":"text","label":"My Commission Expires on","name":"commission-expires","className":"col-md-6","subtype":"text"},{"type":"text","label":"Notary Public State of Indiana","name":"notary-public-state-of-indiana","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"paragraph","subtype":"p","label":"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 of South Bend - 501 Alonzo Watson Drive, South Bend, IN 46601","className":"d-block"}]