MISSOURI DEPARTMENT OF PUBLIC SAFETY DIVISION OF ALCOHOL AND TOBACCO CONTROL AFFIDAVIT STATE OF MISSOURI COUNTY OF ____________ ) ) ) ss. Before me, the undersigned authority, personally appeared ______________________________ , who, being by me duly sworn, deposed as follows: My name is ______________________________ , I am of sound mind, capable of making this affidavit, and personally acquainted with the facts herein stated: I am employed by the Missouri Division of Alcohol and Tobacco Control, and have been for _____ years. I am the evidence custodian/technician for District _____ of the Division of Alcohol and Tobacco Control for Docket No. ______________________________ . On _________________________ , Agent ______________________________delivered the following items to me as follows: The condition of the item(s) that was/were submitted to me by Agent ______________________________ at ________________________ for Docket No. ______________________________ is/are described as follows: After taking the item(s) from the Agent, I then: As evidence custodian/technician, I used the following procedures for identifying and securing the item(s): The next time I saw the item, the condition of the item was: MO 812-1117N (11-03) 1 American LegalNet, Inc. www.FormsWorkflow.com On _________________________ I transferred the item(s) to ______________________________ and the condition of the item was: On _________________________ I retrieved the item(s) Docket No. _________________________ from __________________________ and the condition of the item was: After I retrieved the item(s) from _________________________ I took the item(s) and: Attached hereto is the evidence log for the item(s) listed above. As evidence custodian/technician, I keep and maintain the custody of the custody sheets for Missouri Division of Alcohol and Tobacco Control District No. __________ . These pages of record are kept by the Missouri Division of Alcohol and Tobacco Control in the regular course of business, and it was the regular course of business for an employee or representative of Missouri Division of Alcohol and Tobacco Control with knowledge of the act, event, condition, opinion, or diagnosis recorded to make the record or to transmit information thereof to be included in such record; and the record was made at or near the time of the act, event, condition, opinion or diagnosis. The records attached hereto are the original or exact duplicates of the original. ____________________________________ (Affiant) (Date) STATE OF MISSOURI COUNTY OF ____________ ) ) ) ss. Before me, the undersigned authority, personally appeared __________________________________________________________ , on this __________ day of _________________________ , 20 _____ , who first being duly sworn on his/her oath, states that he/she has read the foregoing Affidavit and the facts contained therein are true and complete to the best of his/her knowledge, information and belief. ____________________________________ Notary Public [Seal] My Commission expires: ______________________________ MO 812-1117N (11-03) 2 American LegalNet, Inc. www.FormsWorkflow.com