Statutory Declaration of Loss of a Receipt

STATUTORY DECLARATION OF LOSS OF A RECEIPT

I, ______, of ______, in the Province of Ontario, SOLEMNLY DECLARE that:

1. On ______, I paid ______ to ______ for ______.

2. The receipt or proof of payment was lost in the following circumstances: ______.

3. I have made diligent efforts to locate it without success, and the payment described above was genuinely made.

4. I make this declaration for the following purpose: ______.

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