LOST DOCUMENT AFFIDAVIT
Executed at __________ on __________.
I, __________, __________, resident of __________, holding __________, ordinarily resident within __________ (the "Deponent" or "I"), do hereby solemnly affirm and declare as follows:
- THE DOCUMENT LOST
1.1 This affidavit concerns the loss of __________, addressed to __________.
- CIRCUMSTANCES OF LOSS
2.1 The document was lost on or about __________. __________.
2.2 Search made before concluding it is lost: __________.
- REPORT AND NOTICE
3.1 __________.
3.2 __________.
- UNDERTAKING AND INDEMNITY
4.1 I undertake that if the original document is subsequently found or comes into my possession or control, I shall immediately surrender it to __________ — or, if it is the passport, deposit it with the passport issuing authority — and shall not use it further.
4.2 I indemnify __________ against any loss, claim, demand or liability arising from the issue of a duplicate or replacement in reliance on this affidavit, or from any statement made here that later proves incorrect.
- DECLARATION
5.1 Every statement made above is true to my own knowledge and belief, and I have concealed nothing material to this affidavit. I am aware that making a false declaration in an affidavit is an offence.
VERIFICATION
Verified at __________ on __________ that the contents of paragraphs 1 to 5 above are true and correct to my own knowledge, that no part of it is false, and that nothing material has been concealed.
DEPONENT
Signature: ______________________________
__________
ATTESTATION
Solemnly affirmed and signed before me on __________ at __________, the Deponent having been identified to my satisfaction by __________.
Notary Public / Oath Commissioner
Registration No. and seal: ____________________