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STATE OF State
COUNTY OF County
Name , of Street address , City , State , ZIP Code , being duly sworn, hereby swears and affirms as follows: Self / For a business
1. Signer Name is an authorized officer, representative, or agent of Name , which is the sole holder (the "Holder") of the promissory note dated Date , in the amount of $$ Amount and signed by Name (the "Borrower") in favor of Name as beneficiary (the "Original Note").
Lost / Stolen / Destroyed
2. The Original Note has been inadvertently lost . The Holder has made the following efforts to locate the Original Note: Description Description .
Monthly / Quarterly / Single payment
3. The Original Note provides for monthly payment(s) in the amount of $$ Amount , with these payments beginning on Date and continuing until the principal and interest have been paid in full .
4. The balance remaining under the Original Note as of Date is $$ Amount .
5. Neither the Original Note nor any part of the Holder's rights in the Original Note has, in whole or in part, been sold, transferred, or assigned to any other person or entity.
6. The existence and terms of the Original Note have not been contested by the Borrower and all conditions of the loan agreement between the Holder and the Borrower have otherwise been met.
Yes / No
7. A correct copy of the Original Note is attached as Exhibit A to this affidavit.
8. If the Holder locates the Original Note, or if it is otherwise returned to the Holder, the Original Note will have no value and the Holder will surrender the Original Note to the Borrower immediately and without consideration.
9. The Holder asks, and is making this affidavit for the purpose of requesting, that the Borrower execute a duplicate note as a substitute for the Original Note.
10. In consideration of the above, the Holder shall:
The Holder is signing this affidavit on the date set forth below.
Date: ______________________
______________________________________
Signature of Signer Name
| STATE OF Affidavit State | |
| COUNTY OF Affidavit County | |
| Subscribed and sworn to before me this __________day of ____________, 20_____, at ___________, __________________. |
| _________________________________________ | |
| Signature of Notary Public | |
| Name of Notary Public: ____________________________ | (SEAL) |
| Notary Public, State of Affidavit State | |
| My commission expires: ___________________________ |
PAGE BREAK HERE
| EXHIBIT A | |
| Attach copy of Original Note. |