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 
(Power Of Attorney) 
 
 
I, ___________________________________, after being first duly sworn, depose and state that: 
 
1. 
I am the Attorney-in-Fact for ________________________________________, 
having been appointed pursuant to the attached copy of a Power of Attorney dated 
___________________. 
2. 
To my knowledge, my appointment has not been revoked. 
3. 
__________________________ is/are the record owner of a ________________ 
(account type) account, maintained at _______________________________________ 
(name of institution) with a balance of $________________. 
4. 
Said account was presumed abandoned, and upon information and belief, is being 
held in trust by the Administrator. 
5. 
After due diligence, I have not been able to locate the passbook or other instrument 
for said account. 
6. 
I 
request 
that 
the 
Administrator 
pay 
the 
amount 
held 
in 
trust 
to 
___________________. 
7. 
I 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. 
8. 
This Affidavit shall be binding on my heirs, executors, and administrators and 
assigns. 
 
 
___________________________________ 
Attorney-in-Fact for Owner 
 
 
Subscribed and sworn to before me this _____ day of _____________________, 20______. 
 
 
____________________________________ 
Notary Public 
 
 
 
 
 
 
           NP#__________________ 
 
 
 
 
 
 
 
Expires:_______________