Statutory Declaration of Lost Document

I, of do solemnly and sincerely declare as follows:

  1. That I am the lawful owner of the following document:
  2. That the said document was lost on or about at
  3. The circumstances leading to the loss are as follows:
  4. Despite all efforts, I have been unable to find or recover the said document.
  5. That should the original document be found, I undertake to return it immediately to the relevant authority.

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the provisions of the Statutory Declarations Act.

Declared at:
Date:
Signature of Declarant:
Before me (Name of Notary/Commissioner):
Signature:
Official Stamp: