Fill and Sign the Affidavit of Lost Stock Certificate Iwe Hereby Form

Affidavit of Loss of Bill of Lading with Agreement to Hold Harmless STATE OF ____________________COUNTY OF _______________________PERSONALLY appeared before me, the undersigned authority in and for said county and state, __________________ (Name of Affiant), who, having been being first duty sworn by the undersigned Notary Public, deposes and says:1. Affiant, being _____ (number) years of age, resides at ____________________ ________________________________________________________________ (street address, city, state, zip code). 2. Affiant is the original ______________ (consignee or consignor) named in Bill of Lading No. ________ (number), dated _________________ (date) , issued by _____________________ (name of issuer).3. On or about ____________ (date), Affiant discovered that the above mentioned document was _________ (lost, destroyed or stolen) in the following manner: (description of events of loss) ______________________________________ ________________________________________________________________ ________________________________________________________________.4. Affiant requests delivery of the goods covered by the document even though surrender of the document has not been made. Affiant agrees to hold harmless and indemnify _________________ (name of carrier) and any person who suffers loss, damage, or injury by delivery of the goods arising out of the delivery with non-surrender of the document.___________________________________ (Printed Name of Affiant)___________________________________ (Signature of Affiant)SWORN to and subscribed before me, this the ____ day of _____________, 20____._____________________________NOTARY PUBLICMy Commission Expires:___________________