GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS 
OFFICE OF THE LIEUTENANT GOVERNOR 
DIVISION OF BANKING, INSURANCE AND FINANCIAL REGULATION 
 
5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: 340-774-7166 • Fax: 340-774-9458 
1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: 340-773-6459 • Fax: 340-719-3801 
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 type) 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 
that the Administrator may sustain from any claims arising from the Administrator’s 
reliance on this Affidavit.  I further agree to repay any such claim together with the 
Administrator’s costs and expenses. 
5. 
This Affidavit shall be binding on my heirs, executors, and administrators and 
assigns. 
 
 
___________________________________ 
Claimant’s Signature 
 
 
Subscribed and sworn to before me this _____ day of _____________________, 20______. 
 
 
____________________________________ 
Notary Public 
 
 
 
 
 
 
           NP#__________________ 
 
 
 
 
 
 
 
Expires:_______________