Affidavit of Lost Document

AFFIDAVIT OF LOST DOCUMENT

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

1. I was the holder of the following document: ______ (reference number: ______), issued by ______.

2. I last had the document in my possession on or about ______.

3. The document was lost in the following circumstances: ______.

4. The document has not been pledged, sold, or transferred by me to any other person, and I have made diligent efforts to locate it without success.

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