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Affidavit Of Loss With Agreement To Hold Harmless
AFFIDAVIT OF LOSS WITH AGREEMENT TO HOLD HARMLESS
STATE OF [State of affidavit]
COUNTY OF [County of affidavit]
[Consignee or consignor or storer], referred to in this affidavit as affiant, being sworn, deposes and says:
(1) Affiant, being [Age of affiant] years of age, resides at [Address of affiant], [City of affiant], [State of affiant].
(2) Affiant is the original [Consignee or consignor or storer] named in [warehouse receipt or bill lading] no. [Bill lading number], dated [Bill lading date], issued by [Bill lading issuer].
(3) On or about [Date of loss], affiant discovered that the above mentioned document was [lost or destroyed or stolen] in the following manner: [Description events of loss].
(4) Affiant 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 or carrier] 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.
Signature Date