AFFIDAVIT FOR 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]
[Jurat]
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