AFFIDAVIT OF LOST INSTRUMENT
GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS OFFICE OF THE LIEUTENANT GOVERNOR DIVISION OF BANKING, INSURANCE AND FINANCIAL REGULATION 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 I/WE, ___________________________________, after being first duly sworn, depose and state that: 1. I/WE am the record owner of a ________________ (account type) 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, INSURANCE AND FINANCIAL REGULATION 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 I/WE, ___________________________________, after being first duly sworn, depose and state that: 1. I/WE am the record owner of a ________________ (account type) 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 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. 5. This Affidavit shall be binding on my heirs, executors, and administrators and assigns. ___________________________________ Claimant’s Signature Subscribed and sworn to before me this _____ day of _____________________, 20______. ____________________________________ Notary Public NP#__________________ Expires:_______________