GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS
GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: 340-774-7166 • Fax: 340-774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: 340-773-6459 • Fax: 340-719-3801 AFFIDAVIT OF LOST INSTRUMENT (Power Of Attorney) I, ___________________________________, after being first duly sworn, depose and state that: 1. I am the Attorney-in-Fact for ________________________________________, having been appointed pursuant to the attached copy of a Power of Attorney dated ___________________. 2. To my knowledge, my appointment has not been revoked. 3. __________________________ is/are the record owner of a ________________ (account type) account, maintained at _______________________________________ (name of institution) with a balance of $________________. 4. Said account was presumed abandoned, and upon information and belief, is being held in trust by the Administrator. 5. …
Download the original document · Plain text (TXT) · Browse the archive · How this archive works
Original source: https://web.archive.org/web/20150626232924id_/http://ltg.gov.vi/downloads/forms/b&i/Affidavit_of_Lost_Instrument_Power_of_Attorney.pdf
SHA-256 30fbd1409f80ef68b8901cf310052edd28b4a53150e1ba8a2c9e701d19ce6f0a
Re-using this document
A public record of the Government of the Virgin Islands, published by the agency itself. No copyright is asserted on it and 17 U.S.C. § 105 does not reach territorial government, so it publishes as a territorial public record.
Our description, tagging, arrangement, extracted text and machine transcripts are released under CC0 1.0. We assert nothing about the document itself.
Archive identifier LF-30fbd1409f80
Document text
GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING AND INSURANCE 5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: 340-774-7166 • Fax: 340-774-9458 1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: 340-773-6459 • Fax: 340-719-3801 AFFIDAVIT OF LOST INSTRUMENT (Power Of Attorney) I, ___________________________________, after being first duly sworn, depose and state that: 1. I am the Attorney-in-Fact for ________________________________________, having been appointed pursuant to the attached copy of a Power of Attorney dated ___________________. 2. To my knowledge, my appointment has not been revoked. 3. __________________________ is/are the record owner of a ________________ (account type) account, maintained at _______________________________________ (name of institution) with a balance of $________________. 4. Said account was presumed abandoned, and upon information and belief, is being held in trust by the Administrator. 5. After due diligence, I have not been able to locate the passbook or other instrument for said account. 6. I request that the Administrator pay the amount held in trust to ___________________. 7. I agree to be responsible and indemnify the Administrator for any and all losses that the Administrator may sustain from any claims arising from the Administrator’s reliance on this Affidavit. I further agree to repay any such claim together with the Administrator’s costs and expenses. 8. This Affidavit shall be binding on my heirs, executors, and administrators and assigns. ___________________________________ Attorney-in-Fact for Owner Subscribed and sworn to before me this _____ day of _____________________, 20______. ____________________________________ Notary Public NP#__________________ Expires:_______________