Free 49555.FH11 - Indiana

AFFIDAVIT
State Form 49555 (R2 / 4-06)

STATE OF INDIANA BUREAU OF MOTOR VEHICLES

} } COUNTY OF MARION } STATE OF INDIANA

ss:

AFFIDAVIT
I, , ("affiant") hereby swear or affirm under penalty

of perjury as follows:

(print name of affiant)

1. That the identity of the individual whose digital photograph appears in the Bureau of Motor Vehicles records
under this affiant's name, address and Social Security number is unknown to me. Transaction number:

2. That any identification presented by said individual to obtain a license, State ID, or other document from the
BMV in this affiant's name was presented without my knowledge or assistance.

3. That I have been advised that any fraudulent license or State ID obtained by means of this affiant's
identification will be investigated by the Indiana State Police and that any false claims made by means of this affidavit may result in the suspension of affiant's drivers license and possible criminal prosecution under the laws of perjury of the State of Indiana.

Signature of affiant

Date (month, day, year)

Signature of Bureau of Motor Vehicles hearing officer