Affidavit of Lost Instrument
GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE Office of the Lt. Governor λDivision of Banking & Insurance λKongens Gade #18 λSt. Thomas, U.S. Virgin Islands λ00802 λPhone (340) -774-7166 λFax (340)-774-9458 or Office of the Lt. GovernorλDivision of Banking & Insuranceλ1131 King Street, Suite 101λChristiansted,St. Croix,U.S.V.I. λ 00820 λPhone(340)773-6449 λFax (340)-773-4052 AFFIDAVIT OF LOST INSTRUMENT I/WE, ______________________________, after being first duly sworn, depose and state that: 1. I/WE am the record owner of a _________________ account, No. __________________ maintained at ____________________ (Name of Institution) in the amount of $______________. Said account is presumed abandoned and is being held in trust by the Administrator. 2. After due diligence I have not been able to locate the passbook or other instrument for said account. 3. I/WE request that the Administrator pay the amount in trust, to ______________________. 4. …
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GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE Office of the Lt. Governor λDivision of Banking & Insurance λKongens Gade #18 λSt. Thomas, U.S. Virgin Islands λ00802 λPhone (340) -774-7166 λFax (340)-774-9458 or Office of the Lt. GovernorλDivision of Banking & Insuranceλ1131 King Street, Suite 101λChristiansted,St. Croix,U.S.V.I. λ 00820 λPhone(340)773-6449 λFax (340)-773-4052 AFFIDAVIT OF LOST INSTRUMENT I/WE, ______________________________, after being first duly sworn, depose and state that: 1. I/WE am the record owner of a _________________ account, No. __________________ maintained at ____________________ (Name of Institution) in the amount of $______________. Said account is presumed abandoned and is being held in trust by the Administrator. 2. After due diligence I have not been able to locate the passbook or other instrument for said account. 3. I/WE request that the Administrator pay the amount in trust, to ______________________. 4. I/WE agree to be responsible and indemnify the Administrator for any and all losses which the Administrator may sustain from any claims arising from the Administrator’s reliance on this Affidavit. I agree to repay any such claim together with the Administrator’s costs and expenses. 5. This Affidavit shall be binding on my heirs, executors, administrators and assigns. __________________________ Claimant’s Signature Subscribed and Sworn to before me this _____ day of _______________, ____________________. ____________________________ NOTARY PUBLIC NP#___________________ EXPIRES.:______________