Affidavit of Loss

Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

AFFIDAVIT OF LOSS

I, {{affiant_name}}, of legal age, {{affiant_nationality}}, and a resident of {{affiant_address}}, after having been duly sworn in accordance with law, do hereby depose and state that:

DETAILS OF LOST ITEM

1. I am the lawful owner/possessor of a certain {{type_of_item_lost}}.

2. The lost item is described as follows: {{description_of_item_lost}}.

3. The serial number/identification number of the lost item is {{serial_or_id_number}} (if applicable).

CIRCUMSTANCES OF LOSS

4. On or about {{date_of_loss}}, at approximately {{time_of_loss}}, in the vicinity of {{place_of_loss}}, the aforementioned {{type_of_item_lost}} was {{circumstances_of_loss, e.g., misplaced, stolen, or lost}} under the following circumstances: {{detailed_explanation_of_loss}}.

5. Despite diligent efforts to locate it, the said {{type_of_item_lost}} could no longer be found.

PURPOSE OF AFFIDAVIT

6. This affidavit is being executed to attest to the truth of the foregoing facts and to request {{action_requested_e.g._replacement_of_document_or_item}} from {{institution_or_authority}}.

7. I am executing this Affidavit to declare the loss of the said {{type_of_item_lost}} for all legal intents and purposes.

UNDERTAKING

8. I hereby undertake to immediately surrender the original {{type_of_item_lost}} to the concerned authorities should it be found or recovered in the future.

STATEMENT OF TRUTH

IN WITNESS WHEREOF, I have hereunto set my hand this {{day}} day of {{month}}, {{year}} in {{city_state_country}}.

Signature Block

_____________________________

{{affiant_name}}

Affiant

SUBSCRIBED AND SWORN to before me this {{day}} day of {{month}}, {{year}} in {{city_state_country}}, affiant exhibiting to me his/her identification card no. {{id_number}} issued on {{date_of_issue}} at {{place_of_issue}}.

NOTARY PUBLIC

NOTARY PUBLIC

Doc. No. {{doc_no}};

Page No. {{page_no}};

Book No. {{book_no}};

Series of {{series_year}}.