STATE OF PENNSYLVANIA
COUNTY OF [County Name]

Introduction:

I, [YOUR NAME], residing at [YOUR ADDRESS], in the County of [County Name], State of Pennsylvania, being duly sworn, declare under penalty of perjury as follows:

Statement of Facts:

1. I am the individual named herein.

2. I am a legal resident of the State of Pennsylvania and I am presenting this affidavit as proof of my identity.

3. This affidavit is made for the purpose of obtaining a replacement for my lost or stolen identification document(s).

4. The following document(s) have been lost or stolen:

   • [Type of Document, e.g., Pennsylvania Driver's License]

   • [Type of Document, if applicable]

   • Date of Loss/Theft: [Date]

   • Place of Loss/Theft: [Location]

5. I affirm that the information provided in this affidavit is true and accurate to the best of my knowledge.

6. This affidavit is made in good faith, without any intention to deceive or commit fraud.

7. Attached are copies of documents that serve as proof of my identity and residency (if applicable), including:

   • [List of Documents]

POLICE REPORT:

I have [not] filed a police report regarding the lost or stolen document(s).

[If applicable] A copy of the police report is attached.

CONTACT INFORMATION:

My current contact information is as follows:

• Phone Number: [YOUR PHONE NUMBER]

• Email Address: [YOUR EMAIL ADDRESS]

Acknowledgement:

I hereby affirm that the information provided in this affidavit is true and correct to the best of my knowledge and belief.

I understand that providing false statements in this affidavit can result in penalties under the law.

Signature:

[YOUR NAME]

Subscribed and sworn to (or affirmed) before me on this [Day] of [Month], [Year], by [YOUR NAME], proved to me on the basis of satisfactory evidence to be the person who appeared before me.

[NOTARY PUBLIC NAME]

Affidavit Templates @ Template.net