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STATUTORY DECLARATION OF SURRENDER OF A DOCUMENT
I, ______, of ______, in the Province of Ontario, SOLEMNLY DECLARE that:
I was the holder of the following document: ______ (reference number: ).
On ______, the document was ______, .
The reason and circumstances are as follows: ______.
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