I, ACCOUNT_FIRST_NAME ACCOUNT_LAST_NAME, residing at ADDRESS, the undersigned do hereby declare and affirm that:

(a) That I am the lawful owner/ holder of the following lost property/document: ITEM

(b) That the above mentioned property/document was lost on: LOCATION_DATE

(c) That despite diligent search and inquiry for the lost property/document, it is nowhere to be found anymore;

(d) That the loss of the said item/document was not caused by any negligence, intentional act, or omission on my part;

(e) That I am executing this Affidavit of Loss to attest to the truth of the foregoing circumstances and for the purpose of PURPOSE

I certify under the penalty of perjury under JURISDICTION_STATE law that information provided herein are true and correct to the best of my knowledge and belief.

Signature: [Signature]

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