Affidavit of Loss

State: Alabama
County: ________

I, the undersigned, do swear and confirm the following facts:

1. My legal name is as follows: ________.

2. My date of birth is ________.

3. My present address and telephone number are as follows:

________
________

4. I am the lawful owner of the following document: Alabama Driver's License, number ________, issued on ________.

5. On or about ________, I lost or discovered the loss of the document described above.

6. The following are the details of how I lost the document:

________

7. I am requesting a replacement of the lost document.

8. I have made all efforts to retrieve the lost document, to no avail.

9. I provided the following form of identification to the Notary Public to prove my identification:

________

10. I am aware that any false information on this Affidavit of Loss is punishable to the fullest extent of the law, up to and including monetary fine or imprisonment.

11. The below is my true and correct signature.

I swear under penalty of perjury that I am the party described above and that all statements in this Affidavit of Loss are true.

________

Signature: _____________________

Date: _________________________

State of Alabama NOTARIZATION:

State: Alabama
County: ________

On the following date: ________________________ before me personally appeared the above signatory. I am a Notary Public in and for the state of Alabama and the signatory above is personally known to me or proved to me on the basis of satisfactory evidence to be the person(s) whose name is signed herein and acknowledged that he/she/they executed the same.

WITNESS my hand and official seal:

Seal:

Name: __________________________________

Signature: _______________________________

My commission expires: ____________________