Indiana Dept. of Natural Resources
Indiana Outdoor Licensing System
402 West Washington Street
Room W160
Indianapolis, IN 46204



State of Indiana
County of  ________________________________________

I, ____________________________, ("Affiant") Hereby State Under

Penalty of Perjury as Follows:

That my name is:        _____________________________________

That my address is:     _____________________________________

                                  _____________________________________

                                  _____________________________________



That I, ___________________________, have never been issued a Social Security Number at any time.
                     Please Print Name


I understand that both § 466(a)(13) of the federal Social Security Act [42 U.S. C. 666(A)(13)] and
Indiana Code § 14-22-11-3 require that I provide a Social Security Number on my application for
any license that I wish to obtain from the State of Indiana and that I am unable to provide a Social
Security Number because such a number has never been issued to me.

I SWEAR OR AFFIRM THAT ALL THE INFORMATION I HAVE ENTERED ON THIS FORM IS CORRECT.
I UNDERSTAND THAT MAKING A FALSE STATEMENT ON THIS FORM MAY CONSTITUE THE CRIME OF PERJURY.


________________________________________      _____________________________
                           Signature of Affiant                                    Date signed (month, day, year)