Affidavit of Lost Cheque or Bank Draft

AFFIDAVIT OF LOST CHEQUE OR BANK DRAFT

I, ______, of ______, in the Province of Ontario, MAKE OATH AND SAY that:

1. A ______ (number ______) in the amount of ______, issued by ______ and payable to ______, was issued on or about ______.

2. It was lost in the following circumstances: ______.

3. The instrument has not been cashed, endorsed, or transferred by me, and I have been unable to locate it.

4. I request that the issuer stop payment and reissue it, and I will return the original if it is found.

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

SWORN / DECLARED before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Declarant