An affidavit of loss is typically used when an important record or document is misplaced, stolen, destroyed or mutilated.
It may be a stock certificate, vehicle title or registration, promissory note, passport or visa, cheque payment etc.
Many financial institutions or government agencies will have a prescribed form which must be completed. However, if you need to compile your own affidavit, then take a look at our free affidavit form further down on this page, which you can edit to suit your requirements.
The particular affidavit sample here is for a lost promissory note but it is a simple matter to change the details of the lost document.
Note: For links to official affidavits and our other free templates, please refer to our Affidavits Page. Also take a look at the step-by-step guidelines to write an affidavit - it will make it very easy to understand the format.
I, the undersigned __________________(full legal name) do hereby make oath and say that:-
1. I am an adult, residing at ________________________(full residential address). The facts contained in this affidavit are within my own knowledge and are true and correct.
2. On the _____day of ________________20__ a Promissory Note in the amount of _____________Dollars ($_____), accruing interest at ____% per annum was executed by __________________( "the Borrower") and sometime during _________________20___ the original Note was lost. Attached hereto, marked "A" is a true copy of the original Note.
2. On the _____day of ________________20__ a Promissory Note in the amount of _____________Dollars ($_____), accruing interest at ____% per annum was executed by __________________( "the Borrower") and some time during _________________20___ the original Note was lost. A copy of the original Note is not available but the terms of the Note call for equal monthly payments starting on the _____ day of ________________20___ and continuing on the first day of every month thereafter until settled in full, where payments are first applied to penalties and late fees, then interest, then arrears and then the principal amount.
3. The total amount outstanding on the Note as of the _____ day of ________________20____ is _____________Dollars ($_____). Attached hereto, marked "B" is a reconciliation reflecting all the payments received and allocated to date.
4. I am the sole current holder of the Note and no part of it has been assigned to another party.
5. I authorize the Borrower to withhold any payment to any third party upon presentation of the original Note and indemnify the Borrower against any costs, damages and expenses which may result from duplicate payments made, upon reliance of this Affidavit and the presentation by me or my assignees or representatives of the original Note.
FULL LEGAL NAME
SWORN TO AND SUBSCRIBED BEFORE ME, on this _____ day of _______________ 20___ at ______________________ State of ______________________.
My commission expires: _____________________
Refer to our main page on Promissory Notes for links to a variety of loan agreements.
Writing an affidavit of loss is a simple document where you just state the facts as to how or when or when an item - any item - was lost.
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