Fillable Lost or Stolen Parking Permit for Persons with (Town of Brookhaven)

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Lost or Stolen Parking Permit for Persons with (Town of Brookhaven)

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Lost or Stolen Parking Permit for
Persons with Disabilities Affidavit
TC-03 rev. 3/18
Donna Lent,
Town Clerk
Lauren Thoden, Deputy Town Clerk
One Independence Hill, Farmingville, NY 11738
(631) 451-9101 FAX: 451-9264
First Middle Last
Address
Signature
Lost or Stolen Parking Permit for Persons with Disabilities Affidavit
Permit # ______________
I, ________________________________________________________________________ of
___________________________________________________,
attest that my assigned Parking Permit for Persons with Disabilities is either lost or stolen. I
acknowledge that I may not be issued any future replacement parking permits for persons
with disabilities.
________________________________
Sworn to me this __________day
of ____________________, 20____
_______________________ Notary Public
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Lost or Stolen Parking Permit for Persons with (Town of Brookhaven)

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Completed 12 February 2021

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