Affidavit of Loss

Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

AFFIDAVIT OF LOSS

I, {{affiant_full_name}}, of legal age, {{affiant_nationality}}, with postal address at {{affiant_address}}, after having been duly sworn in accordance with law, do hereby depose and state that:

STATEMENT OF FACTS

1. I am the lawful owner/possessor of {{lost_item_description}} (hereinafter referred to as 'the lost item').

2. The lost item was issued/obtained on or about {{date_of_issue_or_acquisition}}.

3. The circumstances surrounding the loss are as follows: {{circumstances_of_loss}}. This occurred on or about {{date_of_loss}} at approximately {{time_of_loss}} at {{place_of_loss}}.

4. I have exerted diligent effort to locate the lost item, including {{efforts_to_locate_item}}, but to no avail.

5. The lost item has not been found and I verily believe that it is indeed lost and cannot be recovered.

6. I am executing this affidavit to attest to the truth of the foregoing facts and for the purpose of {{purpose_of_affidavit, e.g., applying for a replacement, reporting for insurance claims, etc.}}.

DECLARATION

I declare under penalty of perjury under the laws of {{country}} that the foregoing is true and correct.

FURTHER AFFIANT SAYETH NAUGHT.

Signature Block

DATED this {{day}} day of {{month}}, {{year}} at {{city}}, {{country}}.

_____________________________

{{affiant_full_name}}

Affiant

Identity Document Type: {{id_type}}

Identity Document Number: {{id_number}}

Issued On: {{id_issue_date}}

Issued At: {{id_issue_place}}

ATTESTATION

SUBSCRIBED AND SWORN to before me this {{day}} day of {{month}}, {{year}} at {{city}}, {{country}}, affiant exhibiting to me his/her {{id_type}} with number {{id_number}} issued on {{id_issue_date}} at {{id_issue_place}}.

NOTARY PUBLIC

_____________________________

Signature of Notary Public

Printed Name: {{notary_name}}

Commission Serial No.: {{commission_number}}

Notary Public for {{city}}

My Commission Expires on {{commission_expiry_date}}

Roll of Attorneys No.: {{roll_number}}

PTR No.: {{ptr_number}} / {{date}} / {{place}}

IBP No.: {{ibp_number}} / {{date}} / {{place}}