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NOTARIZED SWORN STATEMENT OF THE CLAIMANT

Claim Number _________________ After being duly sworn, the affiant states as follows: 1. 2. My full name is ___________________________________. My current address is ____________________________________________ Street Address ______________________________________________________________ City County State ZIP Code 3. My date of birth is: month ___________________, date_________, year____________

___________________________ Signature of Affiant

STATE OF COUNTY OF

) )

Sworn to and subscribed before me this_________ , day of ___________, _____, by _________________________________. (Month) (Year) (Name of person making statement) __________________________________ (Signature of Notary Public) _________________________________________________________ (Print, Type, or Stamp Commissioned Name of Notary Public) ______________________________________________________________ Address of Notary ______________________________________________________________ City County State ZIP Code *Notary must identify the type of government issued photographic identification produced that verifies Affiant's name and date of birth as stated on this form above. Type of identification shown to Notary by Affiant (such as a drivers license, state identification card, passport, or other similar valid government issued photographic identification): ________________________________

* Pursuant to Section 717.124(1), FS, the claimant must produce to the notary photographic identification of the claimant issued by the United States, a state or territory of the United States, a foreign nation, or a political subdivision or agency thereof.

Form DFS-A4-2007, Effective 10-13-10, incorporated into Rule 69I-20.0022, F.A.C.

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