Free 37964.FH11 - Indiana

AFFIDAVIT
State Form 37964 (R2 / 10-05) BUREAU OF MOTOR VEHICLES

STATE OF INDIANA COUNTY OF
Name Address (number and street, city, state, ZIP code)

}

SS:

Deposes and says upon his / her oath that:

I swear or affirm that the information I have entered on this form is correct. I understand that making a false statement on this form may constitute the crime of perjury.
Signature Date (month, day, year)