Fillable Lost Hangtag (Central Connecticut State University)

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Lost Hangtag (Central Connecticut State University)

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Police Department
Central Connecticut State University
Lost Hangtag Affidavit
Today's Date:
I, , certify that the parking hangtag issued to me,
number , has been lost or destroyed. Further, that I did not give the pass to a third party.
I have been advised that any statement(s) made herein which I do not believe to be true, and which
statement is intended to mislead a public servant in the performance of his/her official function, is a
crime under C.G.S. section 53a-157b.
Signed:
State of Connecticut
County of Hartford
ss. New Britain
Personally appeared the signer of the foregoing statement and made oath before me to the truth of the
matters contained therein.
Subscribed and sworn to before me on this
day of
,
Notary Public:
CCSU PD Form # 20
Central CT State University, one of four universities of the Connecticut State University System
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Completed 27 July 2020

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