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 (Deceased Owner) I/WE, ___________________________________, after being first duly sworn, depose and state that: 1. ____________________________, deceased, is 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 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 (Deceased Owner) I/WE, ___________________________________, after being first duly sworn, depose and state that: 1. ____________________________, deceased, is 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 the heirs, executors, and administrators and assigns of the decedent. ___________________________________ Claimant’s Signature Subscribed and sworn to before me this _____ day of _____________________, 20______. ____________________________________ Notary Public NP#__________________ Expires:_______________