Fillable Printable Affidavit of Loss Sample Template

Affidavit of Loss Sample Template

Affidavit of Loss

State of _________ )

) ss.

County of _________ )

The Affiant, _________________,_________________ (title), of lawful age, being first

duly sworn states and avers:

1. That _______________________(cu rren t lessee name) is the original lessee of

Colorado Oil and Gas Lease No.________.

2. That the original of this state lease was in possession of

_______________________(cu rren t lessee name) as is customary with State of

Colorado oil and gas leases.

3. It was approximately ___ year(s) ago that this oil and gas lease and all

original previous state assignments in chain of title was issued to the

Affiant. The Affiant has very recently checked his records and cannot

locate this oil and gas lease and so must assume that it is lost.

FURTHER Affiant sayeth not.

______________________________

Signed

Subscribed and sworn to before me, a Notary Public this ____day of__________, 20___.

by _______________________________________.

My Commission Expires ______________________.

(STAMP) ______________________________

Notary Public