DIY Legal Forms

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Affidavit Of Loss With Agreement To Hold Harmless

STATE OF _____________________

COUNTY OF ____________________

___________________________ (consignee or consignor or storer), referred to in this affidavit as affiant, being sworn, deposes and says:

(1) Affiant, being __________ years of age, resides at __________________________ (address), _________________ (city), _____________ County, __________ (state).

(2) Affiant is the original ____________________________ (consignee or consignor or storer) named in ____________ (warehouse receipt or bill lading) no. ________________, dated ____________, issued by ___________________.

(3) On or about __________ (date), affiant discovered that the above mentioned document was _______________ (lost or destroyed or stolen) in the following manner: __________________________ (Describe events of loss).

(4) Affiant requests delivery of the goods covered by the document even though surrender of the document has not been made. Affiant agrees to hold harmless and indemnify (warehouse person or delivery carrier) and any person who suffers loss, damage, or injury by delivery of the goods arising out of the delivery with non-surrender of the document.

_______________________
Signature

Date:

*** 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)