Lost Passbook/cd Affidavit Form - Department Of The State Treasurer
ADVERTISEMENT
1COMMONWEALTH OF MASSACHUSETTS
Department of the State Treasurer
Abandoned Property Division
th
One Ashburton Place, 12
Floor
Boston, MA 02108-1608
(617) 367-0400
LOST PASSBOOK/CD AFFIDAVIT
1. Being duly sworn under the penalties of perjury I ___________________________________________
(Name)
state I am of full age and reside at _______________________________________________________
(Street)
(City/Town)
(State)
(Postal Code)
(COMPLETE THE FOLLOWING SECTION IF YOU ARE THE ORIGINAL OWNER)
2.
I have not sold, assigned, transferred, nor pledged lost passbook/CD and balance, nor given it away,
nor authorized nor empowered any person or persons, corporation or association, to draw any amount
on same.
The last time I saw the certificate it was with _________________________________________________
at __________________________________________________________________________ on or about
__________________
; that I missed it for the first time on or about ________________________;
(Date)
(Date)
that I have made diligent search for it _______________________________________________________
(place)
___________________________________________________________________________________________________________
that I do not know in whose possession it is, nor where it could be found.
(ALL CLAIMANTS SHOULD COMPLETE THIS SECTION)
3.
In consideration of the payment to one of the said amount, I agree to indemnify THE
COMMONWEALTH OF MASSACHUSETTS and hold harmless for and from all claims and loss, costs,
damages, and expenses which THE COMMONWEALTH OF MASSACHUSETTS may sustain by reason
of the turning over of the said amount to me and by reason further of its refusal hereafter to pay the said
amount to any other person or persons.
__________________________ _____________________ ___________________________________
Bank Name
Passbook or CD Number
Claimant’s Signature
Subscribed and Sworn to before me,
This ___________ day of ______________________________, ______________ A Notary Public in and
for the County of ____________________________ in the State of _______________________________
__________________________________________________
Signature of Notary Public
My Commission Expires __________________________________________
ID# ________________________
Disk\permanent\Affidavits\Lost Passbook Affidavit.doc
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal