AFFIDAVIT OF LOSS WITH AGREEMENT TO HOLD HARMLESS
STATE OF: ____________________________________
COUNTY OF: __________________________________
___________________________ (consignee or
consignor), referred to in this affidavit as affiant, being sworn, deposes and
being __________ years of age, resides at __________________________ (address),
__________________ (city), _____________ (county), __________ (state).
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
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.