AFFIDAVIT OF IDENTITY AND DISTINCTION

(Pursuant to La. R.S. 9:5501.1)

State of Louisiana
Parish of __________________
Before me, the undersigned authority, personally came and appeared:
_____________________________________________________,

whose

mailing

address is _____________________________________________________, and

whose marital status is ______________, who after being duly sworn, deposed as follows:
I,

____________________________________,

being

of

sound

mind,

acknowledge and understand that any intentional falsification of information I am about to

provide shall subject me to penalties for the crime of injuring public records and false swearing.
My full name is _____________________________________. I am ___ years
old and was born on the ____ day of ________________, 19 ___ in (city/parish/county and
state of birth): __________________________________________.
The last 4 digits of my social security number are ______.
I presently reside at _____________________________________________,
and my previous addresses for the preceding 10 years were:
_________________________________________________________________,
_________________________________________________________________.
The name and address of my employer is: ______________________________,
______________________________________________________________, and
the name and address of location of employment is: _____________________________,
______________________________________________________________,
and my occupation is _________________.
My marital status is _________________, (if married), the full name of my spouse is
_______________________________________________ (provide maiden name if
female). The last 4 digits of my spouses social security number are ___________.
I HEREBY AFFIRM AND ATTEST, under penalty of law, that I am not the same person
as the debtor or debtors named in the following described recorded judgments, liens or
privileges:
A _______________ in favor of: _______________________________________;
in the amount of $__________, dated ______________, filed on _________________;
recorded in Mortgage Office Book _____ Folio ____, Instrument number ______________.
A _______________ in favor of: _______________________________________;
in the amount of $__________, dated ______________, filed on _________________;
recorded in Mortgage Office Book _____ Folio ____, Instrument number ______________.
A _______________ in favor of: _______________________________________;
in the amount of $__________, dated ______________, filed on _________________;
recorded in Mortgage Office Book _____ Folio ____, Instrument number ______________.
I HEREBY FURTHER AFFIRM AND ATTEST that on the ____ day of
_________________, 20 ___, I mailed a copy of the affidavit to the creditor listed in the
affidavit at his last known address by registered mail and hereby submit proof of said certified
mailing (mail slip or postal confirmation).

I HEREBY AFFIRM AND ATTEST that the creditor has failed to comply with La. R.S.
9:5501 and I hereby execute this affidavit of identity to establish that I am not the same person
indentified as the debtor in the said recorded judgment, lien or privilege or other such
documents itemized above.
Thus done, read and signed at __________________, this _____ day of
_________________, 20 ___.
Witnesses:

Affiant:

__________________________

____________________________

__________________________
Sworn to this ____ day of _______________, 20 ___.
____________________________
Notary Public
____________________________
Printed Name and ID number

JUDGMENT CREDITOR ACKNOWLEDGMENT

I

(we),

___________________________________________(Name

of

Judgment Creditor), hereby acknowledge that the above named affiant is not the same person
identified or named in the above identified of described ___________________________
(type of document) and that the property of the of the affiant is not subject to the judicial
mortgage resulting from the judgment.
Thus done, read and signed at __________________, this _____ day of
_________________, 20 ___.
Judgment creditor:
___________________________________
(Signature)

___________________________________
(Printed Name)

Title ________________________________
Company Name: _______________________

Sworn to this ____ day of _____________, 20 ___.

____________________________
Notary Public
____________________________
Printed Name and ID number