COUNTY OF ____________________

___________________________ (consignee or consignor or storer), referred to in this affidavit as affiant, being sworn, deposes and says:

(1) Affiant, being __________ years of age, resides at __________________________ (address), _________________ (city), _____________ County, __________ (state).

(2) Affiant is the original ____________________________ (consignee or consignor or storer) named in ____________ (warehouse receipt or bill lading) no. ________________, dated ____________, issued by ___________________.

(3) On or about __________ (date), affiant discovered that the above mentioned document was _______________ (lost or destroyed or stolen) in the following manner: __________________________ (Describe 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