STATUTORY DECLARATION Pursuant to the Statutory Declarations Act 1938 (Ireland) I, [Full Name of Declarant], aged 18 years and upwards, residing at [Address of Declarant, Eircode, Ireland], by occupation a [Occupation / Profession], holder of Georgian Passport No. [Passport Number], DO SOLEMNLY AND SINCERELY DECLARE as follows: 1. [Set out the facts clearly, e.g., That I am currently residing at the address stated above and have resided there continuously since DD/MM/YYYY.] 2. [E.g., That I am financially dependent upon / independent...] 3. [E.g., That I have not entered into any marriage / civil partnership...] AND I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Statutory Declarations Act 1938. DECLARED by the said [Full Name of Declarant] at [Location, e.g. Dublin], in the County of [County] this [Day] day of [Month], [Year] ____________________________________ Signature of Declarant Before me, [Name of Peace Commissioner / Commissioner for Oaths], a Peace Commissioner / Commissioner for Oaths appointed for the County of [County], and I know the Declarant / the Declarant has been identified to me by [Passport No. XXXXXX]. ____________________________________ Peace Commissioner / Commissioner for Oaths Official Stamp / Seal: