AFFIDAVIT
FOR LOST, STOLEN, OR DESTROYED STOCK CERTIFICATE
STATE OF [ins-State]
COUNTY OF
[ins-County]
Before me, a duly
commissioned Notary Public within and for [ins-County] and
[ins-State], personally appeared [s-Name] who, after being duly sworn
as required by law, deposes and acknowledges:
- That I reside at [s-Address], [s-City], [s-State], [s-ZipPostCode]
- That I am the legal and beneficial owner of [s-Number] shares of the [s-Class] stock of [s-Company] 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 [t-Lost-Stolen-Destroyed] of said certificates and my attempt to locate them are as follows:
[Insert Relevant Details]
- That the purpose of preparing this affidavit is to request [s-Company] to issue new certificates in replacement of those that have been [t-Lost-Stolen-Destroyed].
- I hereby agree to surrender to [s-Company] the original certificates issued to me should they hereafter come into my possession or control.
____________________________________________
[s-Name]
SWORN to and
subscribed before me, this the _____ day of __________________, 20
_____.
____________________________________________
NOTARY PUBLIC
My Commission
Expires:
