AFFIDAVIT OF LOSS WITH AGREEMENT TO HOLD HARMLESS

WAREHOUSE RECEIPT

STATE OF: ____________________________________

COUNTY OF: __________________________________

___________________________ (consignee or consignor), referred to in this affidavit as affiant, being sworn, deposes and says:

(1) Affiant, being __________ years of age, resides at __________________________ (address), __________________ (city), _____________ (county), __________ (state).

(2) Affiant is the original ______________________ (consignee or consignor) named in __________ (warehouse receipt) number ________________, dated____________ (month & day), _________ (year), issued by ____________________________________.

(3) On or about __________ (month & day), ______ (year), affiant discovered that the above mentioned document was __________ (lost or destroyed or stolen) in the following manner: __________________________________________ (describe events of loss).

(4) Affiant requests delivery of the goods covered by the document even though surrender of the document has not been made. Affiant agrees to hold harmless and indemnify __________ (warehouseman) and any person who suffers loss, damage, or injury by delivery of the goods arising out of the delivery with non-surrender of the document.

_____________________________________________ _________________

(Signature) (Date)