AFFIDAVIT OF LOST WAREHOUSE RECEIPT
Agreement made __________ (date) between __________
(claimant), of ___________ ____________________ (address), ______________
(city), ______________ County, __________ (state), referred to in this
agreement as claimant, and ________________ (warehouseman), of
_______________________________ (address), ____________ (city), _____________
County, _____________ (state), referred to in this agreement as warehouseman.
1. On __________ (date), claimant stored with
_____________ (warehouseman), at _____________________________________
(address), _________________ (city), __________ County, _________ (state),
certain goods consisting of _____________ (describe goods).
2. Warehouseman issued to claimant its original
warehouse receipt no. __________ on delivery of such goods by claimant.
3. Claimant has lost or mislaid such warehouse
receipt, and the same has not been negotiated by claimant nor has it passed
from __________ (his or her) possession knowingly.
In consideration of delivery to claimant of the
above described goods by warehouseman, without claimant's surrender of the
above-mentioned warehouse receipt, claimant does hereby indemnify warehouseman
against all loss, damages, charges, or other expenses reasonably incurred by
warehouseman by reason of claimant’s failure to return such warehouse receipt
on surrender by warehouseman of such goods.
In witness whereof, the parties have executed this
agreement at __________ (designate place of execution), on __________ (date).
Name of Claimant
(Signature of Authorized Agent)