Free 52012.pdf - Indiana

SOCIAL SECURITY NUMBER AFFIDAVIT
State Form 52012 (1-05)

Indiana Dept. of Natural Resources IndianaOutdoor Licensing System 402 West Washington Street Room W160 Indianapolis, IN 46204

State of Indiana County of ___________________ I, ____________________________, ("Affiant") Hereby State Under
Print name

Penalty of Perjury as Follows:
That my name is: _____________________________________

That my address is: _____________________________________ _____________________________________ _____________________________________ That I, ___________________________, have never been issued a Social Security Number at any time.
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I understand that both § 466(a)(13) of the federal Social Security Act [42 U.S. C. 666(A)(13)] and Indiana Code § 14-22-11-3 require that I provide a Social Security Number on my application for any license that I wish to obtain from the State of Indiana and that I am unable to provide a Social Security Number because such a number has never been issued to me.
I SWEAR OR AFFIRM THAT ALL THE INFORMATION I HAVE ENTERED ON THIS FORM IS CORRECT. I UNDERSTAND THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTITUE THE CRIME OF PERJURY.

____________________________________________________ Signature of Affiant

_____________________________________ Date signed (month, day, year)