Fill and Sign the Lost Stock Certificate Form

Affidavit for Lost, Stolen, or Destroyed Stock Certificate 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. That I reside at __________________________________________________________ _________________________________________ (street address, city, state, zip code) . 2. That I am the legal and beneficial owner of __________ (number) shares of the (specify class) _________________________ stock of ________________________ (name of corporation) represented by certificates described as follows: Number: _________ Date: ________________ Registered Name: ______________ (state number) (state date) _____________________________ (state registered name) 3. That said certificates _______________ (were or were not) endorsed. 4. 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. 5. That I am entitled to full and exclusive possession of said certificates. 6. That the circumstances surrounding the _________________________ (loss, or theft, or destruction, or disappearance) of said certificates and my attempt to locate them are as follows: (explain) __________________________________________________ ______________________________________________________________________ . 7. That the purpose of preparing this affidavit is to induce __________________________ (name of corporation) to issue new certificates to replace those that have been ______________ (lost, stolen, destroyed) . 8. That I hereby agree to surrender to _______________________ (name of corporation) the original certificates issued to me should they hereafter come into my possession or control. ________________________________ (Printed Name of Affiant) ________________________________ (Signature of Affiant) SWORN to and subscribed before me, this the _____ day of _____________, 20____. _____________________________ NOTARY PUBLIC My Commission Expires: ___________________