Statutory Declaration of Surrender of a Document

STATUTORY DECLARATION OF SURRENDER OF A DOCUMENT

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

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

2. On ______, the document was ______, ______.

3. The reason and circumstances are as follows: ______.

4. The document is no longer in my possession or control.

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