This affidavit may be used by a person who has lost or misplaced official school
documents or records, such as a diploma or transcripts. This document will allow such
a person to make, as an affidavit made under oath, an official request for the school,
university or other institution to replace the missing document. This document may be
modified to allow its use in situations when the documents will be replaced for no cost,
and when there is a fee that will be imposed for the document's replacement.
AFFIDAVIT--re Request for Replacement of Official School Records or Documents
From:
____________________
____________________ {Instruction: Provide current full legal name and current address.
Also provide school ID number and any other information that will be helpful for the school
to identify you.}
I, _____________ [NAME OF PERSON REQUESTING THE DOCUMENTS], with the date
of birth: ____________ [PROVIDE FULL BIRTH DATE], with the permanent mailing
address of ___________________________, was/am enrolled in the following course or courses
at _________________ [PROVIDE NAME OF SCHOOL OR UNIVERSITY]:
________________________________ {Instruction: Provide all the course names and
identifying course numbers or course codes.}. I attended/have been attending
________________ [NAME OF SCHOOL, AS ABOVE] during the following term(s):
_____________________ {Instruction: Provide the details describing when you attended. For
example, “Fall 2004, Fall 2005, and Spring 2006.” Or, “Fall 2004 until Spring 2008.” Add
as many additional lines as necessary.}
I do hereby swear and/or affirm, under penalty of perjury, as follows:
I was/am at present {Instruction: Choose one of the two options. Delete or cross out the other
option.} studying in _________________ [NAME OF THE COURSE OR COURSES, OR
PROGRAM OF STUDY] in the ______ [SPECIFY SEASON AND YEAR]
quarter(s)/term(s)/semester(s) {Instruction: Specify which term applies to your school, and
delete or cross out the others that do not apply.}. I received all the documents and statements
pertaining to my studies. I now have, however, discovered that the following item(s) and/or
document(s) or school record(s) is/are missing from my records: _____________________
[DESCRIBE ALL THE MISSING DOCUMENTS THAT YOU ARE REQUESTING
FROM THE SCHOOL].
Therefore, I am requesting that _______________ [NAME OF SCHOOL, and (if relevant)
NAME OF PROGRAM OR COURSE OF STUDY] send me the following documents and/or
records: ____________________ {Instruction: Specify which document(s) you need. For
example: “Full transcripts from Fall 2001 until Fall 2006”, or “Final grades report card
from Spring 2003 semester”, or “Full transcripts and proof of my Magna Cum Laude status”,
etc...}
My current full legal name is ___________________. However, during the period when I
attended your school, my legal name at the time was ___________________ and that is the name
that appears on the records or documents that I am requesting. {Instruction: Include this
paragraph only if relevant. Delete if not relevant.}
I am informed and believe that there is no fee for requesting the above document(s).
[OR]
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I have been informed that there is a total fee of $ _______ for the processing and mailing of the
above document(s). A check for this amount is enclosed.
All of the above are true and correct. I will indemnify you and your authority if any disputes
arise in the above matter and I will be held responsible for the same.
Please send the requested document(s) to the following address: ________________
Sincerely,
_______________________
_______________________
_______________________ {Instruction: Signature, print full name, and address}
DEPONENT:
PLACE :
DATE :
Solemnly affirmed and signed before me at
……….. (Place) on this ……………. (dated)
(Seal & Sign of Notary Public)
© Copyright 2013 Docstoc Inc. registered document proprietary, copy not 3
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