Sworn Statement of True Name and Pseudonym. If you receive any other income, fill in the source and the amount.Under penalty of perjury, I swear (or affirm) that the foregoing answers are true and complete and that the requested report will not be used for commercial. An Affidavit is a sworn statement which must be signed in front of a notary public. 1. Complete only the upper half of the affidavit. This affidavit will be attached to the original birth certificate thus becoming part of the birth record.