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Sample Affidavit / Sworn Statement

A worked sworn statement with numbered facts, an exhibit, a belief qualification, filing purpose and jurat.

Jurisdiction: General illustrative affidavit — an authorised oath-taker, prescribed jurat and court rules may apply

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Important: This sample provides general legal information only and is not legal advice. Check the law, prescribed forms and signing requirements that apply to your exact jurisdiction and circumstances before use.

AFFIDAVIT OF NORA ELAINE RIVERA

Important jurisdiction and formalities warning

This fictional affidavit is a general worked example, not legal advice and not a universally valid court form. The court, tribunal or authority receiving an affidavit may require a particular heading, prescribed wording, page numbering, exhibit marking, oath or affirmation, remote-commission procedure, translation, filing fee, or service method. The deponent must sign only before a person authorised in the relevant jurisdiction to administer oaths or affirmations. Check the applicable procedural rules and obtain legal advice before relying on this statement.

1. Deponent and purpose

I, Nora Elaine Rivera, of 52 Juniper Street, Bellhaven, Eastland 60214, project manager, say on oath or solemn affirmation as follows. I make this affidavit in support of my application to the Bellhaven Civil Tribunal concerning the damaged equipment supplied under purchase order BH-7741 by Pioneer Event Systems Ltd of 9 Foundry Park, Bellhaven, Eastland 60218.

I am over eighteen years old and competent to give this evidence. Unless I identify information received from another person or a document, the facts in this affidavit are within my own knowledge. Where I state information supplied by another person, I believe it to be true and identify its source. I make this affidavit in good faith for use in the proceeding and not for any improper purpose.

2. The agreement and delivery

On 3 March 2026, Bellhaven Arts Cooperative, for which I manage production, accepted Pioneer’s written quotation for a package of twelve wireless stage microphones, charging equipment and two receiver units. The agreed price was 18,460 Eastland dollars, including delivery and the applicable sales tax. The quotation stated that delivery would occur by 21 March 2026 for our 28 March 2026 public performance.

On 21 March 2026, Pioneer delivered two cartons to the cooperative’s rehearsal venue at 14 Lantern Wharf, Bellhaven, Eastland 60214. I was present with our technician, Lewis Grant, when the cartons were opened. The outer packaging was wet and one carton had a crushed lower corner. I took photographs immediately and retained the delivery note. The delivery note records the words “carton damaged; inspection pending,” which I wrote before signing for delivery.

On the same day, Lewis and I tested each microphone using the supplied receivers. Four microphones would not power on, and the two receiver units produced intermittent audio and repeated signal loss. The remaining eight microphones operated for short periods but cut out during a fifteen-minute test. We used fresh batteries and the supplied charging equipment. We did not alter or repair the equipment.

3. Notice and attempted remedy

At 4:35 p.m. on 21 March 2026, I emailed Pioneer’s service address and attached photographs of the packaging and a list of the failed serial numbers. A true copy of that email and its attachments is exhibited to this affidavit and marked Exhibit NR-1. Pioneer’s service coordinator, Tomas Vale, replied on 22 March 2026 and asked us to return the equipment for inspection.

On 23 March 2026, Pioneer collected all twelve microphones and both receivers. Its driver gave me a collection receipt. On 25 March 2026, Tomas told me by telephone that Pioneer had dried the equipment and would return it on 27 March. I asked whether the receivers had been replaced or tested under performance conditions. He said that no replacement receivers were available and that Pioneer had not completed a sustained test.

The equipment returned on 27 March 2026. Four microphones still did not power on. During a thirty-minute test, the two receivers again lost signal. Because our performance was the following day, the cooperative hired replacement equipment from Silverline Audio Hire for 2,750 Eastland dollars. I authorised that payment and the cooperative’s finance officer has retained the invoice.

4. Loss and requested order

The cooperative used the replacement equipment at the performance and returned it on 29 March 2026. On 1 April 2026, I requested a refund of the purchase price and reimbursement of the reasonable hire charge. Pioneer rejected the request on 8 April 2026 and said that the damage was caused by our handling. I disagree. The equipment was defective when opened, the packaging was already wet and damaged, and the cooperative followed Pioneer’s written testing instructions.

I ask the Tribunal to consider the purchase price of 18,460 Eastland dollars, the replacement hire cost of 2,750 Eastland dollars, filing costs if recoverable, and any other remedy available under the governing law. I do not ask the Tribunal to decide facts outside my personal knowledge without appropriate evidence.

5. Truth statement

I have read this affidavit. The facts stated from my own knowledge are true. The facts stated from information or belief are honestly believed to be true, and the sources have been identified where material. I understand that knowingly making a false statement in an affidavit may have legal consequences.

Sworn or affirmed by Nora Elaine Rivera at Bellhaven, Eastland on 10 April 2026.

Deponent signature: ____________________

Before me: Celia Maren Holt, Notary Public and authorised oath administrator

Signature and seal: ____________________ Commission expiry: 30 June 2029

The commissioner should complete only the form of jurat permitted by the applicable jurisdiction and should confirm identity, capacity, exhibits and any required interpreter or remote-signing safeguards.

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