Form Pwd-1083 - Affidavit For Recreational License Applicant Claiming To Have No Social Security Number

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Affidavit for Recreational License Applicant
Claiming to have No Social Security Number
Section A: Affiant Information
First Name:
M.I.:
Last Name:
Sr.
Jr.
Mr.
Mrs.
Other
Ms.
Other
Section B: Physical Address
Address:
City:
State:
Zip Code:
Contact Information
Primary Phone Number:
Mobile Phone (Optional):
(
)
(
)
Date of Birth
Place of Birth (City):
State:
Zip Code:
Country:
(mm/dd/yyyy):
E-mail Address (Optional):
Drivers’ License Number:
State:
Section C: Certification
As a prerequisite to the issuance of a recreational license by the Texas Parks and Wildlife Department, I certify under
penalty of perjury that the above information is true and correct and that I have never been issued or assigned a social
security number by the Social Security Administration or any other agency of the federal government of the United States
of America.
Signature:
Date Signed
(mm/dd/yyyy):
Section D: Warning
Falsifying information on documents is a punishable offense. Texas Penal code, Chapter 37, Section 37.10. Any
person who knowingly makes a false entry in or false alteration of a governmental record is guilty of a felony of
the third degree punishable by confinement in jail for any term of not more than 10 years or less than 2 years and
punished by a fine not to exceed $10,000.
Texas Parks and Wildlife Department maintains the information collected through this form. With few exceptions, you are entitled to be informed
about the information we collect. Under Sections 552.021 and 552.023 of the Texas Government Code, you are also entitled to receive and review
the information. Under Section 559.004, you are also entitled to have this information corrected.
4200 Smith School Road, Austin, Texas 78744
(800) 792-1112 ● (512) 389-4800
PWD 1083 – A0900 (01/08)

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