AFFIDAVIT OF LOSS

I, , of legal age, , and with residence at , after having been duly sworn in accordance with law, do hereby depose and state:

  1. That I am the lawful owner of .
  2. That on or about , I discovered that the said was lost at or around .
  3. Despite diligent efforts to locate and recover said item/document, such efforts have proven futile.
  4. That said loss was not due to my fault or negligence.
  5. That I am executing this Affidavit to attest to the truth of the foregoing and for whatever legal purpose it may serve.
Done this day of , 20, at .
Affiant
SUBSCRIBED AND SWORN to before me this
day of , 20 at .
Notary Public
Doc. No. ;
Page No. ;
Book No. ;
Series of .