***AFFIDAVIT FOR REPLACEMENT BALLOT***

The owner listed below declares and certifies under penalty of perjury under the laws of the State of California as follows:

PROPERTY OWNERS NAME *
PROPERTY OWNERS NAME
PROPERTY ADDRESS
PROPERTY ADDRESS
MAILING ADDRESS
MAILING ADDRESS
CHOOSE ONE OF THE FOLLOWING:
REPLACE THE FOLLOWING:
Choose one option
Date
Date
I, the undersigned, do hereby declare and certify under penalty of perjury under the laws of the State of California that I am the legal owner of the property listed above and that the statements I have submitted are truthful.