***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
Type your Full Legal Name - 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.