Flood Loss Sworn Statement Affidavit

Policyholder Name:

Address:

Policy Number:

Claim Number:

Sworn Statement

I, , being duly sworn, depose and say: That I have suffered a loss at caused by flood on .

The total amount of the loss and damages claimed is:

I further state that the information provided is true and correct to the best of my knowledge, and that no material facts have been withheld.

Description of Loss and Damages:

Signature of Policyholder

Date

Subscribed and sworn before me this

day of , .

Notary Public

My commission expires