Affidavit of Lost Promissory Note and Indemnity Agreement - EDIT

STATE OF 
COUNTY OF 

, of , , , , being duly sworn, hereby swears and affirms as follows: 

1. is an authorized officer, representative, or agent of , which is the sole holder (the "Holder") of the promissory note dated , in the amount of $ and signed by   (the "Borrower") in favor of as beneficiary (the "Original Note").

2. The Original Note has been inadvertently loststolendestroyed. 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 monthlyquarterlyone lump-sum payment(s) in the amount of $, with these payments beginning on  and continuing until the principal and interest have been paid in full, with these payments beginning on  and continuing until the principal and interest have been paid in full.

4. The balance remaining under the Original Note as of  is $.

5. Neither the Original Note nor any part of the Holder's rights in the Original Note has, in whole or in part, been sold, transferred, or assigned to any other person or entity.

6. The existence and terms of the Original Note have not been contested by the Borrower and all conditions of the loan agreement between the Holder and the Borrower have otherwise been met.

7. A correct copy of the Original Note is attached as Exhibit A to this affidavit.A copy of the Original Note is not available, but the Holder hereby states that the terms of the Original Note as stated in this affidavit are correct.

8. If the Holder locates the Original Note, or if it is otherwise returned to the Holder, the Original Note will have no value and the Holder will surrender the Original Note to the Borrower immediately and without consideration.

9. The Holder asks, and is making this affidavit for the purpose of requesting, that the Borrower execute a duplicate note as a substitute for the Original Note.

10. In consideration of the above, the Holder shall:

• (a) release the Borrower from all claims, suits, or causes of action the Holder may have against the Borrower relating to the Original Note or the Borrower's compliance with the Holder's request in this affidavit; and
• (b) indemnify the Borrower against all losses relating to:
  • (i) the issuance and delivery of a new note;
  • (ii) any payment, transfer, delivery, exchange, or other act related to the Original Note, whether done by accident, oversight, or neglect, or whether made or done on presentation of the Original Note, without contesting the propriety of that payment, transfer, delivery, exchange, or other act;
  • (iii) the Original Note or the Company's compliance with the Holder's request in this affidavit; or
  • (iv) any breach or violation of a representation or covenant in this affidavit.

The Holder is signing this affidavit on the date set forth below.

Date: ______________________

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Signature of

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