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 (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 To my knowledge, my appointment has not been revoked. 3.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. …
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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 (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 To my knowledge, my appointment has not been revoked. 3.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:_______________