AFFIDAVIT OF LOSS

STATE OF ________
COUNTY OF ________

I, the undersigned affiant, being first duly sworn upon oath, depose and state as follows:

1. My full legal name is ________.
2. My date of birth is ________.
3. My current residential address and telephone number are as follows:
   ________
   ________
4. I am the lawful owner of the following document (the "Document"): ________ Driver's License, number ________, issued on ________, with an expiration date of ________.
5. On or about ________, I lost, misplaced, or otherwise discovered the loss of the Document described above.
6. The circumstances of the loss of the Document are as follows:
   ________
7. The Document has not been sold, assigned, pledged, hypothecated, transferred, or otherwise disposed of by me, and is not in my possession or under my control.
8. I have made diligent and reasonable efforts to locate and recover the Document, all of which have been unsuccessful, and I have no knowledge of its present whereabouts.
9. I hereby request the issuance of a duplicate or replacement of the lost Document.
10. In the event the original Document is subsequently found or recovered, I agree to surrender it promptly to the issuing authority.
11. I provided the following form of identification to the Notary Public to verify my identity:
    ________
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14. The statements set forth herein are made for the purpose of inducing the issuance of a replacement of the Document.

I declare and swear under penalty of perjury under the laws of the State of ________ and of the United States that I am the person described above and that all statements contained in this Affidavit of Loss are true, correct, and complete to the best of my knowledge and belief.

Affiant Name: ________

Signature: ________

Date: ________

ACKNOWLEDGMENT AND JURAT

STATE OF ________
COUNTY OF ________

Subscribed and sworn to (or affirmed) before me on this ________, by ________, who is personally known to me or who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument, and acknowledged to me that he or she executed the same in his or her authorized capacity, and that by his or her signature on the instrument the person executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of ________ that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Notary Public Signature: ________

Printed Name of Notary: ________

My Commission Number: ________

My Commission Expires: ________

(Affix Notary Seal Below)

________