This form must be signed in the presence of a Notary Public.
AFFIDAVIT OF LOST STOCK CERTIFICATE
I, <Full Name>, do under oath depose and say:
I am of legal age.
I am the legal owner of record of <number of shares> shares of the stock of <Corporation>, appearing on the books and records of the Corporation as certificate <number(s)>:
- <list of certificates>
After a due and diligent search for said stock <certificate(s)> I have determined them to be lost or misplaced. Said <certificate(s)> <is/are> not endorsed and <has/have> not been sold, pledged, transferred or in any way encumbered.
I agree that should said <certificate(s)> be located and fall under my control that I will return and surrender them to <Corporation> without delay or consideration.
I agree to indemnify and hold harmless <Corporation> for any and all claims of ownership of said original <certificate(s)>, and do hereby request <Corporation> to issue <replacement(s)>.
IN WITNESS WHEREOF, and under the penalties of perjury, I affix my hand this <Day> day of <Month>, <Year>.
__________________________________________________
<Full Name>
STATE OF <State>, COUNTY OF <County>, ss.:
I, __________________________________, do hereby certify that on this
______ day of ________, __________, personally appeared before me
____________________________________________________________,
known to be the person(s) who executed the foregoing instrument.
__________________________________________
Notary Public in and for the State of _________________.
My commission expires _______________.
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