Instructions: Please read carefully

1. Complete the following information (*=Required) and print this form
2. Part 1 must be completed by owner on ATA records
3. Part 2 is completed if certificate was lost by someone other than owner on ATA records
4. DNA is required
5. Remit fee: $100.00 (pay via PayPal or mail with check/credit card information to the ATA) along with $60 for a DNA kit
6. If a change in ownership needs to be processed, include a properly completed transfer report with fee of $30.00

Part 1: To be completed in ALL INSTANCES by recorded owner:

I,* , hereby affirm that the sentence marked below describes the circumstances surrounding the loss or destruction of the certificate for the horse identified in this affidavit.

One of the boxes below must be marked in order for us to proceed *:
            I lost the certificate
            I never received the certificate from the ATA
            I mailed or delivered the certificate to: NAME:
                                                                        ADDRESS:
                                                                 If given to an auction company, please list the date of the sale:
            Other (explain)

The undersigned agrees to indemnify and hold harmless the ATA from any and all liability, whenever or however arising, by virtue of its reliance on this affidavit and its issuance of the replacement certificate; agrees to defend the ATA at his expense; and if judgment is made against the ATA, to pay judgment and obtain written release in form acceptable to the ATA.

Sworn to before me this ____ day of ______________, ______                       ____________________________________________
                                                                                                                                 Signature of Recorded Owner

Notary Public ________________________________________                       ____________________________________________
                                                                                                                                 Address

My commission expires________________________________                       ____________________________________________
                                                                                                                                 City                       Address               State       Zip

                                                                                                                              ____________________________________________
                                                                                                                                 Owner's Phone Number

                                                                                                                              ____________________________________________
                                                                                                                                 e-mail address

Mail Certificate to: _______________________________________________________
                                     Name

                                            __________________________________________________________________________
                                                 Address

                                            __________________________________________________________________________
                                                 City                                              Address                                                 State       Zip

                                            __________________________________________________________________________
                                                 Daytime telephone number

                                            __________________________________________________________________________
                                                 e-mail address

Enclosures:
        Four Recent Photos     Owner Transfer Form     Bills of sale, unbroken chain of ownership

Part 2: To be completed IN ADDITION to Part 1 if the certificate was not lost by recorded owner:

I,* , hereby affirm that the sentence marked below describes the circumstances surrounding the loss or destruction of the certificate for the horse identified in this affidavit.

One of the boxes below must be marked in order for us to proceed *:

I lost the certificate

I never received the certificate from the ATA

I mailed or delivered the certificate to: NAME:                                                                         ADDRESS:      If given to an auction company, please list the date of the sale:

Other (explain)

The undersigned agrees to indemnify and hold harmless the ATA from any and all liability, whenever or however arising, by virtue of its reliance on this affidavit and its issuance of the replacement certifiate; agrees to defend the ATA at his expense; and if judgement is made against the ATA, to pay judgement and obtain written release in form acceptable to the ATA.

Sworn to before me this ____ day of ______________, ______                       ____________________________________________
                                                                                                                                 Signature of Person requesting Certificate (not recorded owner)

Notary Public ________________________________________                       ____________________________________________
                                                                                                                                 Address

My commission expires________________________________                       ____________________________________________
                                                                                                                                 City                       Address               State       Zip

                                                                                                                              ____________________________________________
                                                                                                                                 Owner's Phone Number

                                                                                                                              ____________________________________________
                                                                                                                                 e-mail address