I __________, residing at the following address __________, being of legal age, depose and say that:

1. That I can no longer locate the original __________ originally signed or produced __________
   

2. I am requesting a replacement of the lost document.
   

3. That I made efforts to locate the document but all efforts to retrieve the said document have proved abortive.
   

4. That I am in need of certified true and correct copy of the document at this time.
   

5. I am aware that any false information on this Affidavit of Lost document is punishable to the fullest extent of the law, up to and including monetary fine or imprisonment.
   

6. The below is my true and correct signature.