I am first duly sworn and state I am: Name. Hennepin County Affidavit of Identity and Survivorship Form.Fill in the blank form formatted to comply with all recording and content requirements. 1.1. This form is intended to be filed with the IRS in the case of: 1.1.1. These requirements apply to all grad uate nurse positions in the following and related services: (i) Hospitals (some times referred to as staff nurse, general. All documents submitted must be originals or certified copies.