GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS 
OFFICE OF THE LIEUTENANT GOVERNOR 
DIVISION OF BANKING AND INSURANCE 
Office of the Lt. Governor λDivision of Banking & Insurance λKongens Gade #18 λSt. Thomas, U.S. Virgin Islands λ00802 λPhone (340) -774-7166 λFax (340)-774-9458 
or 
Office of the Lt. GovernorλDivision of Banking & Insuranceλ1131 King Street, Suite 101λChristiansted,St. Croix,U.S.V.I. λ 00820 λPhone(340)773-6449 λFax (340)-773-4052 
 
AFFIDAVIT OF LOST INSTRUMENT 
 
 
I/WE, ______________________________, after being first duly sworn, depose and state that: 
 
1. I/WE am the record owner of a _________________ account, No.        __________________ 
maintained at ____________________ (Name of Institution) in the amount of $______________.  
Said account is presumed abandoned and is being held in trust by the Administrator. 
 
2. After due diligence I have not been able to locate the passbook or other instrument for said account. 
 
3. I/WE request that the Administrator pay the amount in trust, to ______________________. 
 
4. I/WE agree to be responsible and indemnify the Administrator for any and all losses which the 
Administrator may sustain from any claims arising from the Administrator’s reliance on this 
Affidavit.  I agree to repay any such claim together with the Administrator’s costs and expenses. 
 
5. This Affidavit shall be binding on my heirs, executors, administrators and assigns. 
 
 
  
 
 
 
 
 
 
 
__________________________ 
 
 
 
 
 
 
 
 
Claimant’s Signature 
 
Subscribed and Sworn to before me this _____ day of _______________, ____________________. 
 
 
 
____________________________ 
NOTARY PUBLIC 
 
NP#___________________ 
 
EXPIRES.:______________