Affidavit for Lost, Stolen, Destroyed
Stock Certificate Form

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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