Affidavit of Lost, Stolen, Destroyed Stock Certificate

State of ____________.

County of ___________.

I, [name], being duly sworn, state:

That I reside at [address], [city], [state] That I am the legal and beneficial owner of [number] shares of the [specify class] stock of [corporation] represented by certificates described as follows:

Number

Date

Registered Name

That said certificates [were or were not] endorsed.

That I have not assigned, hypothecated, pledged, or in any other way disposed of either the stock certificates or my rights as a stockholder, in whole or in part.

That I am entitled to full and exclusive possession of said certificates.

That the circumstances surrounding the [loss, or theft, or destruction, or disappearance] of said certificates and my attempt to locate them are as follows:

That the purpose of preparing this affidavit is to induce [corporation] to issue new certificates to replace those that have been [lost, stolen, destroyed].

I hereby agree to surrender to [corporation] the original certificates issued to me should they hereafter come into my possession or control.

Dated:_________.

____________________

Signature

*** If Required By FederaL or State Law ***

This Section for Notary:

ACKNOWLEDGMENT

State of _________

County of ________ [COUNTY]

On [DATE] before me, [NAME OF NOTARY], notary, personally appeared [NAME OF PERSON(S) INVOLVED], personally known to me (or proved to me on the basis of satisfactory evidence) to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal.

Signature ________
Notary

My commission expires: _____

(Seal)