AFFIDAVIT OF LOST PROMISSORY NOTE
STATE OF: __________) ) SS COUNTY OF :________) _________________, [Insert Name] (the “Holder”), of __________________________ [Insert Address] being duly sworn, does hereby swear and affirm as follows: 1) The Holder is an authorized officer, representative, or agent of _________________, (the “Company”), which is the sole holder of that certain promissory note dated as of ____________, in the amount of _________________________________ ($ ___________________) and duly executed by _________________________ (the “Borrower”) in favor of ________________, as beneficiary (the “Original Note”). 2) The Original Note has been inadvertently [lost] [stolen] [destroyed]. [The Holder has made the following efforts to locate the Original Note] [The destruction of the Original Note occurred as follows]: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________________________________. 3) The Original Note provides for [monthly] [quarterly] [one lump sum] payment[s] in the amount of ______________