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Attachment I -- 251 NAC, Chapter 4 -- SAMPLE

AFFIDAVIT FOR LOST, DESTROYED OR STOLEN CREDENTIALS DELETED UNITS ONLY

Nebraska requires the return of the permanent plate, if you are unable to return the permanent plate. This affidavit MUST accompany supplement.

Name of Company Carrier Account Number

Trailer Unit

UNIT # YEAR & MAKE

VIN

Fleet Number Power Unit

CGW

PLATE #

The undersigned hereby states that the permanent apportion plate assigned to the above vehicle has been:

Lost Stolen Destroyed, and will no longer be in use

ONE OF THE ABOVE BOXES MUST BE MARKED OR AFFIDAVIT WILL BE RETURNED

Signature

Title

Sworn to before me and subscribed in my presence this

day of

, 20

.

Notary Public

My Commission Expires

Motor Carrier Services, PO Box 98935, Lincoln NE 68509-8935; Toll Free 888-622-1222

1/2000

printed on recycled paper

_

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