AFFIDAVIT OF LOSS TEMPLATE AND DEFINITION

Affidavit of loss is a legal document which contains a sworn statement declaring:

  • The physical loss of a item/security through theft or destruction.
  • The owner's name and all the information pertaining to the security
  • The serial number or date of issue
  • The details regarding the loss, particulars and description of the situation which led to the loss.
  • A request to receive a bond of indemnity and replacement of the lost security
  • If can or cannot provide supporting documentation

Documents such as a copy of a police report or a copy made of a security can be attached to a loss report to provide documentation.

Used to recover documents or items damaged as result of floods or fires as well as thefts or other events, such as theft and fraud.

Most common used for the loss of:

  • IDs
  • Passports
  • Vehicles' titles
  • Certificates of title for real estate
  • Certificates indicating ownership of securities.

Blank affidavits of loss which people can fill out are widely available, but your best option is to consult with a lawyer who can prepare a most detailed document better fit to your needs.

AFFIDAVIT OF LOSS


I, __________________________, of legal age, married/single, domiciled and residing at ______________________________________________ being duly sworn do hereby subsequently attest that:

I am the true and lawful owner of ________________________________ which is more particularly described as:

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

That on ____________________, I lost ____________________ at __________________.

Details of the Situation: 

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

I DO have proof of ownership of said documents/items mentioned above.

or

I DO NOT have the necessary documents confirming the ownership because ______

___________________________________________________.

I further declare that all efforts I have made to find the lost item have been unsuccessful and that I consider the item to be irretrievable.

I swear under penalty of perjury under the laws of the state of ______________, county of _________________ that the above is true and accurate on this _________ day of ____________, 20___.


__________________

Affiant


NOTARY PUBLIC

Subscribed and sworn to (or affirmed) before me on this this _________ day of ____________, 20___ by _______________________________________ proved to me on the basis of satifactory evidence to be the person to who appeared before me.


_____________________

Notary Public in and for 

the State of _______________

My commission expires on ___/___/____.


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Affidavit of Loss
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