Statutory Declaration of Non-Receipt

STATUTORY DECLARATION OF NON-RECEIPT

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

1. I was expecting to receive the following ______: ______, from ______.

2. It was expected on or about ______, with an amount or value of ______.

3. I did not receive it. The circumstances, and what I have done about it, are as follows: ______.

4. To the best of my knowledge, the item has not come into my possession or control.

5. I make this declaration to support a refund, reissue, or claim, 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.

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

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Declarant