Riverside County Department of Public Social Services
AFFIDAVIT
Case Number:
I, ____________________________________, declare under penalty of perjury under the laws of the State
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of California that the statement given below is true and correct to the best of my knowledge and belief:
Any person who signs this statement and who willfully states as true any material matter which he knows
to be false is subject to the penalties prescribed for perjury in the penal code by the State of California,
Section 11054 of the W&I code.
SIGNATURE OF PERSON MAKING DECLARATION
ADDRESS
DATE OF DECLARATION
CITY
STATE
ZIP CODE
WITNESSED BY: (Optional)
PHONE NUMBER
TITLE
DPSS 1917 (REV. 4/15) AFFIDAVIT (GENERAL PURPOSE)
