I verify that the statements made in this affidavit are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.Use the form with the boxes to guide you through filling out the blank form. Box 1: Print the name of the county in which you filed exactly as you wrote on. This form is an affidavit (sworn statement), which means that you are certifying that all information you put on the form is correct. Introduction to representing yourself in Pennsylvania. Each of the documents listed below include a blank form and the instructions to fill out that form. This form indicates that the allegations in your Complaint are, to the best of your knowledge, true and correct. Step 4b: Irretrievable Breakdown Divorce - 3301(d)​​ You will complete the Affidavit of Separation after you have been separated from your spouse for a year. There is evidence that the parties held themselves out as married.