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 PAYMENT OF CERTAIN DEBTS WITHOUT ADMINISTRATION Pursuant to Section 89, Title 15 of the Virgin Islands Code I/WE, ___________________________________, after being first duly sworn, depose and state that: 1. Name of the decedent: _________________________________________________ 2. The date of death of the decedent: _________________________________________ 3. The relationship of the affiant to the decedent: ______________________________ 4. That no executor or administrator has qualified or been appointed; 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 PAYMENT OF CERTAIN DEBTS WITHOUT ADMINISTRATION Pursuant to Section 89, Title 15 of the Virgin Islands Code I/WE, ___________________________________, after being first duly sworn, depose and state that: 1. Name of the decedent: _________________________________________________ 2. The date of death of the decedent: _________________________________________ 3. The relationship of the affiant to the decedent: ______________________________ 4. That no executor or administrator has qualified or been appointed; 5. The names and addresses of the persons entitled to and who will receive the money paid; and Name:___________________________ Name:______________________________ Address: _________________________ Address: ____________________________ _________________________ ____________________________ _________________________ ____________________________ 6. That such payment and all other payments made, by all debtors, known to the affiant, after diligent inquiry, do not in the aggregate exceed such amount of $5,000 as provided by regulation promulgated by the Lieutenant Governor of the Virgin Islands. ___________________________________ Date: ________________________ Claimant’s Signature Subscribed and Sworn to before me this _____ day of _____________________, 20______. ____________________________________ Notary Public NP#__________________ Expires:_______________