SAMPLE NOTARY STATEMENTS
Sample Notary Statements for the following forms:
- Acknowledgments
- Oaths
- Depositions
- Affidavits
- Certificates
- Verifications
Acknowledgments
An acknowledgment is a formal declaration before an
authorized official such as a notary public by a person who has signed
a document, that the document is his or her act. Acknowledgments are
governed by the Uniform Acknowledgment Act.
The person acknowledging the document must personally
appear before the notary.
In addition, the person must sign the document in
the notary’s presence, or acknowledge that the signature on the document
is his or her own.
An acknowledgment of any instrument may be made within
this state before:
(1) A judge of a court of record;
(2) A clerk, prothonotary or deputy prothonotary or deputy clerk of
a court having a seal;
(3) A recorder of deeds or a deputy recorder of deeds;
(4) A notary public;
(5) A District Justice, magistrate or alderman.
Acknowledgments within the United States:
An acknowledgment of any instrument may be made without
the state, but within the United States, or territory or insular possession
of the United States, or the District of Columbia, and within the jurisdiction
of the officer before --
(1) A clerk or deputy clerk of any federal court;
(2) A clerk, prothonotary or deputy prothonotary or deputy clerk of
any court of record of any jurisdiction;
(3) A notary public;
(4) A recorder of deeds.
Acknowledgments without the United States:
(1) An ambassador, minister, charge d‘affaires, counselor
to or secretary of a legation, consul general, vice-consul, commercial
attaché or consular agent of the United States accredited to
the country where acknowledgment is made;
(2) A notary public of the country where acknowledgment is made;
(3) A judge or clerk of a court where acknowledgment is made.
SAMPLE ACKNOWLEDGMENTS
By an individual

On this, the______day of __________, 2013, before
me a notary public, the undersigned officer, personally appeared Mary
Jones, known to me (or satisfactorily proven) to be the person whose
name is subscribed to the within instrument, and acknowledged that she
executed the same for the purposes therein contained.
In witness hereof, I hereunto set my hand and official
seal.
___________________________
Notary Public

Statement of venue indicates the state and county
in which the notarization occurs. A notary's jurisdiction is co-extensive
with the boundaries of the commonwealth. Pennsylvania notaries may not
notarize documents outside of the state. The date of the acknowledgment
can be later than the date of the instrument but in no instance may
the date of the document be later than the date of the acknowledgment
By a corporate officer
On this, the________day of __________, 2013, before me a notary public,
the undersigned officer, personally appeared John Smith, who acknowledged
himself to be the President of ABC ENTERPRISES, INC, a corporation,
and that he as such officer, being authorized to do so, executed the
foregoing instrument for the purpose therein contained by signing the
name of the corporation by himself as President.
In witness hereof, I hereunto set my hand and official
seal.
___________________________
Notary Public
By an attorney-in-fact
On this, the____day of __________, 2013, before me a notary public,
the undersigned officer, personally appeared Harvey Anyone, known to
me (or satisfactorily proven) to be the person whose name is subscribed
as attorney in fact for John Smith, and acknowledged that he executed
the same as the act of his principal for the purposes therein contained.
In witness hereof, I hereunto set my hand and official
seal.
_________________________________
Notary Public
If someone claims to be able to sign for another,
a demand to see the power of attorney is required. In real estate matters
the power of attorney must be formally acknowledged before a notary
public so that it can be recorded along with the real estate deed, deed
of trust, mortgage, or other document. A power of attorney can be either
witnessed by one or more persons or notarized. Does not require both.
Keep in mind that a notary cannot act as both a witness and as a notary
on the same document.
By a Pennsylvania attorney-at-law pursuant to 42
Pa.C.S.A. 327
Subscribed, sworn to and acknowledged before me by
John Jones, known to me (or satisfactorily proven) to be the person
described in the foregoing (Instrument or type of document) who acknowledged
that he/she executed the same in the capacity therein stated, and for
the purposes therein contained, and subscribed and sworn to before me
by______________________, the witness, this_______ day of____________,
20__.
______________________________
Adam Smith, Esquire
Member of the Bar of the
Supreme Court of Pennsylvania
I.D. #

On this, the____day of __________, 2013, before me a notary public,
the undersigned officer, personally appeared Adam Smith, Esquire, known
to me (or satisfactorily proven) to be a member of the bar of the highest
court of said state and a subscribing witness to the within instrument
and certified that he was personally present when John Jones, whose
name is subscribed to the within instrument executed the same for the
purposes therein contained. In witness hereof, I hereunto set my hand
and official seal.
_________________________________
Notary Public

No one, other than a member of the Bar of the Supreme
Court of Pennsylvania, may act as a subscribing witness before a notary
public unless the principal is present at the time that the instrument
is notarized.
By a Pennsylvania attorney-at-law pursuant to 20
P.S. 3132.1 under the probate code
Subscribed, sworn to and acknowledged before me by
___________________, known to me (or satisfactorily proven) to be the
person described in the foregoing (Instrument or type of document) who
acknowledged that he/she executed the same in the capacity therein stated,
and for the purposes therein contained, and subscribed by ________________________
and ________________________, the witnesses, this _______ day of ________
20__.
______________________________, Esquire
Member of the Bar of the
Supreme Court of Pennsylvania
I.D. #

On this, the____day of __________, 2013, before me a notary public,
the undersigned officer, personally appeared Adam Smith, Esquire, known
to me (or satisfactorily proven) to be a member of the bar of the highest
court of said state and a subscribing witness to the within instrument
and certified that he was personally present when John Jones, whose
name is subscribed to the within instrument executed the same for the
purposes therein contained.
In witness hereof, I hereunto set my hand and official
seal.
_________________________________
Notary Public

No one, other than a member of the Bar of the Supreme
Court of Pennsylvania, may act as a subscribing witness before a notary
public unless the principal is present at the time that the instrument
is notarized.
Acknowledgment of signing by mark
IN WITNESS WHEREOF, I, ____________________ being
unable to sign my name because of advanced age or infirmity, have had
my name subscribed for me and at my direction by (Witness #1), whereupon
I have made my mark unassisted, in the space between my names, this________day
of__________, 20__.
(First Name - written by witness)
*Subscriber’s Mark Here*
(Last Name - written by witness)
On this, the____day of__________, 20___, the above named (name of person
making the mark) in our presence declared the above preceding (type
of document) consisting of this and ___ other pages to be his/her own
act or deed, and being unable to sign his/her name to the document because
of advanced age and/or infirmity, directed his/her name to be subscribed
for him/her, which the undersigned, (Name of Witness #1), did subscribe
as directed, in his/her presence, made his/her mark in the space provided,
between his/her name, and we, in his/her presence, and in the presence
of each other have subscribed our
names as witnesses.
_______________________________
Witness #1
_______________________________
Witness #2

On this, the ____ day of _____________, 20___ before me, the undersigned
officer, personally appeared___________________, known to me (or satisfactorily
proven) to be the (declarer, grantor, etc), and, who being unable to
affix his/her signature to the within instrument, placed his/her mark
thereon, and directed his/her name to be subscribed thereto and acknowledge
that he/she executed the same for the purposes therein contained.
In Witness Whereof I hereunto set my hand and official
seal.
_________________________________
Notary Public

Acknowledgment by persons serving in or with the
Armed Forces of the United States
In addition to the acknowledgment of instruments in
the manner and form as otherwise now or hereafter authorized by the
laws of this State or by this act, persons serving in or with the Armed
Forces of the United States or their dependents wherever located may
acknowledge the same before any commissioned officer in active service
of the armed forces of the United States with the rank of Second Lieutenant
or higher in the Army, Air Force or Marine Corps or Ensign or higher
in the Navy or Coast Guard. The instrument shall not be rendered invalid
by failure to state therein the place of execution or acknowledgment.
No authentication of the officer’s certificate of acknowledgment shall
be required but the officer taking the acknowledgment shall endorse
thereon or attach thereto a certificate substantially in the following
form:
On this_____day of__________, 20_____
Before me__________________________
The undersigned officer personally appeared ___________________(Serial
No.) (if any) known to me (or satisfactorily proven) to be (serving
in or with the
armed forces of the United States) (or a dependent of)________________(Serial
No.) (if any) A person serving in or with the armed forces of the United
States and to be the person whose name is subscribed to the within instrument
and acknowledgment that he executed the same for the purposes therein
contained. And the undersigned does further certify that he (she) is
at the date of this certificate a commissioned officer of the rank stated
below and is in the active service of the armed forces of the United
States.
____________________________________
Signature of the Officer
____________________________________
Rank & Serial No. of Officer and
Command to which attached
Oaths
An oath is a formal declaration or promise to perform
an act faithfully and
truthfully or an affirmation of the truth of a statement. Oaths are
usually given for three purposes: (1) That a statement is the truth;
(2) That the testimony he or she will be giving will be the truth; (3)
That he or she will faithfully perform the duties of a public office.
SAMPLE OATHS
Notary:
Do you solemnly swear that the statements contained in this
affidavit are true to the best of your knowledge and belief?
Affiant: I
do.
Notary:
Do you solemnly swear that the testimony that you are about to
give will be the truth, the whole truth, and nothing but the truth.
Affiant: I
do.
Notary Public's Oath of Office
I, Joe Q. Notary, having been duly appointed and commissioned
a Notary Public in and for the Commonwealth of Pennsylvania, do solemnly
swear (or affirm) that I will support, obey and defend the Constitution
of the United States and the Constitution of this Commonwealth and that
I will discharge the duties of my office with fidelity.
Depositions
A deposition is an involuntary, or voluntary, sworn
statement made by a witness for use in the witness’ absence at a legal
proceeding. In taking a deposition, the notary should first make sure
the witness is sworn in. The notary should then personally record or
supervise the recording of the testimony of the witness. After the testimony
is transcribed the notary should let the witness read and sign the transcribed
copy of the deposition. The notary then certifies that the witness was
sworn and that the document is a true and accurate record of the witness’
testimony. The deposition should be sealed in an envelope and filed
with the court or sent to the prothonotary for filing. If a videotaped
deposition is requested, the notary should make sure the witness is
sworn. However, it is unnecessary to have a stenographic transcript
and the witness’ signature. The videotape should be given to the attorney
for the party requesting the deposition.
The certificate for a transcribed deposition should
comply with the following format:

Certificate of Officer Before Whom Deposition
is Taken
I,__________________(Name of Officer), a Certified
Court Reporter and Notary Public do hereby certify that, pursuant to
________________(Specify the stipulation, notice or order of court under
which the deposition was taken) the deposition of John Doe (Witness)
was duly taken at ___________(Place) on __________(Date) at __________o’clock
___m. before me. The said John Doe (witness) was first duly sworn (or
affirmed) by me according to law to tell the truth, the whole truth
and nothing but the truth and thereupon did testify as set forth in
the above transcript of testimony. The testimony was taken down by me
or in my presence stenographically by _______(Name of stenographer)
under my direction.
I do further certify that the above deposition is
full, complete and a true record of all the testimony given by the said
witness.
___________________________
Officer
Affidavits
An affidavit is a voluntary, written, sworn statement.
The name of the affiant, the person giving the statement,
must be mentioned in the affidavit and the affiant is required to sign
the affidavit in the notary’s presence. The notarization of an affidavit
guarantees that (1) the affiant personally appeared before the notary
public (2) that the affiant was identified by the notary public and
(3) the affiant was sworn by the notary public to tell the truth.
SAMPLE AFFIDAVIT

Before me, the undersigned notary public, this day,
personally, appeared _____________ to me known, who being duly sworn
according to law, deposes the following:
(Affiant’s Statement)
(Signature of Affiant)
Subscribed and sworn to before
me this__________day of
_______________, 20___.
_____________________
Notary Public

(A corporation cannot give an affidavit. An officer of a corporation,
however, can.)
The date of the notarization on an affidavit must
always be the date that the affiant signed the affidavit. The Jurat
is a certification by a notary or other authorized officer of the time,
place and person before whom the affiant was sworn.
SAMPLE CREDIBLE WITNESS AFFIDAVIT:
Under the penalties of perjury, I (name of credible
witness) declare that the person appearing before Alvin Notary is personally
known to me as (name of person whose signature is to be notarized) and
is the person named in the document requiring notarization.
_______________
Date
______________________________
Witness Signature

Sworn to and subscribed before me this 1st day of
July, 2013, by (Name of Witness) who is personally known to me.
_________________________
Alvin Notary, Notary Public

A credible witness must be personally known to the notary and must personally
know the signed and must appear with the signer.
Certificates
A notary public may certify that a document is an
accurate copy of an original document, or that a statement is true.
The notary public must make sure that the copy is exactly the same as
the original.
Pennsylvania notaries public may not certify certain
Federal, state or county records. Only the Custodians of Records of
the agencies where these records are filed may certify copies, because
they alone hold the original documents or records. This would include
the following:
- Birth records
- Death records
- Marriage records
- Divorce Decree
- Corporate records i.e. Articles of Incorporation
SAMPLE CERTIFICATE

I certify that the attached copy of a ________________________________
dated _____________________________ is a true, correct and complete
copy of the original_________________________.
In witness whereof, I hereunto set my hand and official seal this ____
day of _______, 2006.
___________________________
Notary Public
Verification
A written statement of fact supported by oath or affirmation
or made subject to the penalties of perjury under 18 Pa. C.S. 4904 that
a statement or pleading is true, located at the end of a document.
SAMPLE VERIFICATION AFFIDAVIT FORM
I, John Smith, swear (or affirm) and verify that the statements made
in the foregoing complaint are, to the best of my knowledge, information
and belief, true and accurate.
Dated _____________
_______________________
John Smith
Subscribed and sworn to before me this__________day of________, 2013
_____________________________
Notary Public

SAMPLE NON AFFIDAVIT FORM
By signing below, I verify that this form is in the original format
as supplied by ______________________ and has not been altered or otherwise
modified in any way.
I am aware of the criminal penalties for tampering
with public records or information pursuant to 18 Pa. C.S. §4904.
Additionally, I certify that the statements in this application are
true and correct to the best of my knowledge, information and belief,
and that I am of good moral character. I understand that any false statement
made is subject to the penalties of 18 Pa. C.S. §4904 relating
to unsworn falsification to authorities.
Dated___________________
________________________
John Smith
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