GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS 
OFFICE OF THE LIEUTENANT GOVERNOR 
DIVISION OF BANKING AND INSURANCE 
 
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 
(Deceased Owner)  
 
 
I/WE, ___________________________________, after being first duly sworn, depose and state 
that: 
 
1. 
____________________________, 
deceased, 
is 
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 the heirs, executors, and administrators and assigns 
of the decedent. 
 
 
___________________________________ 
Claimant’s Signature 
 
 
Subscribed and sworn to before me this _____ day of _____________________, 20______. 
 
 
____________________________________ 
Notary Public 
 
 
 
 
 
 
           NP#__________________ 
 
 
 
 
 
 
           Expires:_______________