Statutory Declaration of Lost or Stolen Identification

STATUTORY DECLARATION OF LOST OR STOLEN IDENTIFICATION

I, ______, of ______, in the Province of Ontario, SOLEMNLY DECLARE that:

1. I was the lawful holder of the following identification: ______ (number ______), issued by ______.

2. The document was ______ in the following circumstances: ______.

3. Where the document was stolen and reported to police, the report number is ______.

4. The document has not been transferred, sold, or used by me since that time, and I have been unable to recover it.

5. I make this declaration to support the issuance of a replacement, for the following purpose: ______.

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

DECLARED before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Declarant