I, , of legal age, , and residing at , after being duly sworn to in accordance with law, do hereby depose and state:

1. That I am the owner/holder of ;
2. That the said was lost on or about in ;
3. That despite diligent efforts, I could not find or recover the lost item/document;
4. That this affidavit is executed to attest to the truth of the foregoing and for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this day of 20 at .