INSTRUCTIONS:  Complete the following information including the lost, stolen, or returned permit number.  Write a complete statement about how the hangtag was lost or stolen, or the reason for the return of the hangtag.  Sign and date the statement.

TRANSACTION NUMBER:___________________________________________________

LOT LOCATION:_________________________________________________

NEW LOCATION:_________________________________________________

NEW HANGTAG NUMBER:_____________________________________________

*NAME: __________________________ *E-mail:___________________

*SOCIAL SECURITY: ___________________

*LOCAL ADDRESS:___________________________________________________

____________________________________________________________

*TELEPHONE NUMBER:   (H)_______________    (W)______________

*LICENSE PLATE NUMBER: ____________________

*EXPLANATION: ___________________________________________________________

___________________________________________________________

___________________________________________________________

*LEAVING THE UNIVERSITY: ___________          DATE:___________

*STOP PAYROLL DEDUCTIONS: ________           DATE: __________

*SIGNATURE: _____________________________  DATE: __________

WITNESS: ________________________________   DATE: __________