Free 31540.PDF - Indiana

LIFETIME REPLACEMENT AFFIDAVIT
State Form 31540 (R3 / 3-02) Department of Natural Resources / Fish and Wildlife Division

FOR OFFICE USE ONLY
New license number

Replaces number

INSTRUCTIONS: Fill in all license information below (Please print legibly) Mail your affidavit to: Licenses DNR Customer Service Center 402 West Washington Street, Room W160 Indianapolis, IN 46204-2781

Date

Check number ____________________ Money order number _______________ Certified number

Name of applicant (last, first, middle)

Sex Male Female

Address (street or rural route number, city, state, ZIP code)

County

Birthdate (month, day year)

Telephone number ( )

1. Was your original license: Lost? Stolen? Destroyed?

2. What was your original license type?

3. When was it purchased?

OATH AND SIGNATURE I, the undersigned, being duly sworn on oath, say that I am the party directly responsible for and holding Lifetime License: Type ____________________________________________ Number ______________________ , and that said Lifetime License was indeed lost, stolen or defaced. I, therefore, request the replacement of said Lifetime License.
Signature of applicant Name (printed or typed)

STATE OF ___________________________ SS COUNTY OF ___________________________ SS

Subscribed and sworn to before me this ___________________________________________ day of ____________________________ , 20 _______ .
County Signature of Notary Public

(SEAL)

Date Commission expires

Name (printed or typed)