Affidavit/Application: Lost or Stolen Boating Permit

I, the undersigned, do hereby swear or affirm, that I was issued  Town of Lake Lure boating Permit #_______, pursuant to Town Ordinance "85.51 Permit Fee; Boating Permit Required," for the sum of $_________.

I certify that this boat was replaced or the original permit was lost or stolen (indicate replaced, lost or stolen) and I hereby request that a replacement permit be issued, this ____ day of __________, _________, for the replacement fee of $10.00.

Signature _______________________________

Printed Name ____________________________

Address_________________________________

              _________________________________

State of North Carolina

County of Rutherford

On this ____day of ___________, _____, in my official capacity, I have witnessed this Affidavit/Application.

                                    Executed this ____day of __________, _____.

Signature__________________________ Title ________________

Printed name _______________________ Printed title__________

Address _______________________________________________

My commission expires: