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Affidavit Of Loss, Destruction, Or Theft Of A Negotiable Instrument

STATE OF ----------)

) s.s.:

COUNTY OF ---------)

[Name], being duly sworn, deposes and says:

1. On [date], I received a check drawn by [name] of [date], payable to my order, in the sum of ---------- dollars ($----------), and drawn on the [Bank].

[Alternative Paragraph A]

1. On [date], I received a note made by [name] of [date], payable to my order on [date], in the sum of ---------- dollars ($----------), at the [Bank].

[Alternative Paragraph B]

1. On [date], I received a draft drawn by [name] of [date], payable to my order twenty days after sight, in the sum of ---------- dollars ($----------), which was accepted by [name] on [date], payable at the [Bank].

2. This Check [or, Note, Draft] was lost [or, destroyed, stolen] in the following manner and under the following circumstances: [description].

3. The purpose of this affidavit is to attest to the loss [or, destruction, theft] of the instrument and to induce the party liable for its payment to make payment to me.

[Alternative Paragraph]

3. The purpose of this affidavit is to attest to the loss [or, destruction, theft] of the instrument so that I may maintain an action in my name to recover the amount due on the instrument from any party liable on the instrument, upon proof of ownership, of the terms and conditions of the instrument, and of the facts preventing its presentment.

4. I warrant that neither I nor anyone acting on my behalf have indorsed or will indorse this instrument, and agree to indemnify and hold harmless both Drawer and Drawee [or, Maker] against any loss they [or, it] may incur on the original instrument.

[signature]

Affiant

Sworn to before me

[dated]

[signature]

*** If Required By FederaL or State Law ***

This Section for Notary:

ACKNOWLEDGMENT

State of _________

County of ________ [COUNTY]

On [DATE] before me, [NAME OF NOTARY], notary, personally appeared [NAME OF PERSON(S) INVOLVED], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

Signature ________
Notary

My commission expires: _____

(Seal)