AFFIDAVIT FOR PROPERTY LOSS
I, ________________________________hereby attest, under penalty of perjury, that the
(insert your name)
information contained in this affidavit is true and correct to the best of my knowledge and belief.
1. The information below presents an accurate description of property that I owned and lost
at the time of the terrorist incident.
2. I am requesting reimbursement for the items described below through ITVERP.
3. I have provided a detailed description for each item and its estimated cost at the time of
purchase.
4. I have included a description of the records that I have attached to the application as
supporting documentation where I do not have copies of receipts.
5. I have provided an explanation for why no additional supporting documentation is
available.
6. I confirm and attest that the items I have submitted to ITVERP for reimbursement were
lost or destroyed as a direct result of the terrorist incident. These property loss items
represent an immediate, out-of-pocket expense to me, the undersigned.
7. I hereby confirm and attest that at the time of the incident when these items were lost or
destroyed,
Please select one of the following two options.
I did not have homeowners, renters, or travelers insurance, or any other form of
coverage that could be responsible for the replacement costs for these items.
I did have homeowners, renters, or travelers insurance, or another form of coverage that
could be responsible for the replacement costs for these items at the time of the incident
and have attached the documentation.
__________________________________ __________________________________
(Insert name of insurance carrier) (Insert policy number)
