AFFIDAVIT

North Carolina
Gates County

___________________________ appearing before me, the undersigned
Register of Deeds, assistant or deputy, and being first duly sworn, states
that:

1. I am applying for a marriage license in Gates County North
Carolina, and

2. I have not been issued a social security number by the US
Government. I am ineligible to obtain a social security number.

____________________________ Affiant

Sworn to, or affirmed before me, this the _______ day of __________