I hereby certify, that I have applied (or paid) for but have not received the item indicated above, that the information given above is true and corre...
AFFIDAVIT OF NON-RECEIPT T NON - RECEIPT OF REGISTRATION WITH STICKER T NON - RECEIPT OF CAB CARD WITH STICKER T NON - RECEIPT OF CERTIFICATE OF TITLE
CHECK ONE:
VEHICLE OR BOAT DESCRIPTION Year
Make
Model Vehicle or Hull Identification Number
Engine Number (if applicable)
Body Type (Series) Yr. or Mo./Yr. Reg.
Plate or Boat No.
YEAR OR MONTH/YEAR STICKER APPLIED FOR: PAYMENT MADE BY:
T CHECK
(Attach copy of both sides of cancelled check)
T CASH
TMONEY TOTHER
ORDER
T CASHIER'S CHECK
I hereby certify, that I have applied (or paid) for but have not received the item indicated above, that the information given above is true and correct and that my address given below has not changed. Name of Applicant (please type or print) Address City, State, Zip Code Signature of Applicant
