Notarized Statement Ownership Form – Fill Out and Use This PDF

BRK Brands, Inc. • 3901 Liberty Street Road

Aurora • Illinois 60504-8122

Tel: 630-851-7330 • Fax 630-851-7995

NOTARIZED STATEMENT OF OWNERSHIP FOR COMBINATIONS OR KEYS

Be advised: To avoid delays in processing request, please print clearly and complete all information requested below. You may submit the completed form via fax or mail (address and fax number located in the above right hand corner).

Customer Account #: _____________________

Item(s) Requested: _____ Combination	_____ Keys	_____ Combination & Keys		_____ Override Passcode
Select method you wish to receive combination	and/or override passcode		:

Mail (address below) ___ FAX (number below) ___ CALL*(number below) ___

*Please specify persons at the number below we can release the combination and/or override passcode to:

________________________________________________________________________________________

If keys, please specify type of keys and quantity desired:

Steel Cash & Security Box Keys cost $7.95 and are only sold as a pair – (Do not require a notary letter) All other safe model keys cost $10.95 each – (notary letter is required)

ACCEPTABLE FORMS OF PAYMENT: CASHIERS CHECK, MONEY ORDER OR BUSINESS/PERSONAL CHECK

_______ Override/Master		_______ Standard, Entry or Companion
	(used to open the safe without a combination or passcode)	(used to open safe with a combination or passcode)

*Keys will ship regular US Postal Service to address listed below, please allow 10-14 business days for receipt once order is placed.

_______ Expedite Please ($24.35 Additional Fee, please allow up to 3 business days for receipt once order is placed)

I, __________________________________________, declare that I am the legal and rightful owner of the safe.

(Print Name)

Please circle: if you are the Power of Attorney, an authorized company representative, or estate executor for the rightful safe owner. (You must provide the necessary court-ordered or other supporting documents)

Model #: __________________		Serial #: ______________________________			Key #: ___________
Model #: __________________		Serial #: ______________________________			Key #: ___________
__________________________________________________________________________________________
(Name)			(Business Name – if applies)
__________________________________________________________________________________________
(Address)			(Apt or Unit Number)
__________________________________________________________________________________________
(City, State, Zip)
__________________________________________________________________________________________
TELEPHONE (Area Code + Phone Number)			FAX (Area Code + Number)
____________	__________________________________________________				_______________________________
(Date)	(Signature of Safe Owner or Authorized Person selected above)				(Print Name of Safe Owner)
State of: _____________				Notary Public Seal or Stamp
County of: _________________________				(if notary seal raised or embossed and faxing, please shade over the seal)

Sworn to and subscribed before me

This _____ day of __________, 20 _____.

My commission expires on: ____________, _____, 20 _______

**NOTE: SIGNATURE OF NOTARY MUST BE WITNESSED IN THE PRESENCE OF A NOTARY PUBLIC OF NO RELATION TO YOU**

____________	___________________________________________________	_______________________________
(Date)	(Signature of Notary)	(Print Name of Notary)