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Rev.

1/18/2014
SEPA CLUB INC.
Attn: Key Committee
6020 Camp Cypress Road SEKeyKeeper@yahoo.com
St. Cloud, FL 34773 SEPAClubInc@aol.com


NOTIFICATION OF BROKEN KEY

Please be advised that I, (print name) , am the owner of Key
Number , which was issued to me by the SEPA Club Inc. Key Committee. I am
hereby notifying you that my key broke on and that, with this statement, I
am applying/requesting the Key Committee to issue another key in my name.

I understand that to obtain a new key I must return the TOP PART of the broken key displaying the Key
Number along with this form and the key fee of Thirty Dollars ($30.00) payable to SEPA Club Inc. (cash*,
money order or cashiers check) which includes sales tax and certified mail costs. (*Mailing cash is risky;
SEPA Club Inc is not responsible for lost, stolen, or misdirected mail.)

The forms below are required to be on file. If all three (3) items below are current and on file, a
replacement key can be issued without resubmitting said documents; otherwise, please send the
following:

____ 1) Legible copy of CURRENT Recorded Deed of Ownership
____ 2) Legible copy of CURRENT tax statement (not receipt)
____ 3) Legible copy of CURRENT Picture I.D. (drivers license, passport, employer I.D., etc.)

Please contact Rita Hemphill, Key Chairperson at 407-948-9363 (cell) AFTER 5:00 pm with any
questions. Email is a quicker and preferred method of contact

Print Name
Contact Phone Number:
Address:

Parcel Number:

Email address:



Key Owner Signature


Print Name

OFFICE USE ONLY

____ BROKEN KEY TOP: #
CURRENT DOCUMENT VERIFICATION:
____ DEED: Bk ________/ Pg ________
____ TAX STATEMENT: Year: ________
____ PICTURE I.D. Exp _____________
____ PAYMENT: CA / MO / CshrCk

NEW KEY NUMBER
DATE KEY MAILED: