Affidavit of Loss

COMPANY LETTERHEAD

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

AFFIDAVIT OF LOSS

DEPONENT'S DETAILS

I, {{deponent_name}}, a major, of legal age, residing at {{deponent_address}}, after having been duly sworn in accordance with law, do hereby depose and state that:

CIRCUMSTANCES OF LOSS

1. I am the lawful owner/possessor of {{description_of_lost_item}}.

2. The said {{description_of_lost_item}} was lost on or about {{date_of_loss}} at approximately {{time_of_loss}} at {{place_of_loss}}.

3. The circumstances surrounding the loss are as follows: {{detailed_circumstances_of_loss}}.

4. I have exerted diligent efforts to locate the said {{description_of_lost_item}} but to no avail. The item is truly lost and cannot be recovered.

PURPOSE OF AFFIDAVIT

5. This affidavit is being executed to attest to the truth of the foregoing facts and to request for {{action_requested_e.g._replacement_of_lost_item}}.

ATTESTATION

IN WITNESS WHEREOF, I have hereunto set my hand this {{day_of_signing}} day of {{month_of_signing}}, {{year_of_signing}} at {{place_of_signing}}.

SIGNATURE BLOCK

___________________________

{{deponent_name}}

Deponent

SUBSCRIBED AND SWORN to before me this {{day_of_swearing}} day of {{month_of_swearing}}, {{year_of_swearing}} in {{place_of_swearing}}, affiant exhibiting to me his/her {{identification_type}} with No. {{identification_number}} issued on {{date_of_issue}} at {{place_of_issue}}.

NOTARIAL STATEMENT

NOTARY PUBLIC

Doc. No. {{document_number}};

Page No. {{page_number}};

Book No. {{book_number}};

Series of {{series_year}}.