Fill and Sign the Stock Certificate 497329858 Form

Affidavit for Issuance of New Stock Certificate with Supporting Facts Affidavit of ____________________________________________ (Name of Owner of Lost Stock Certificates) STATE OF ____________________________________ COUNTY OF __________________________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, ________________________________________________ (Name of Owner of Lost Stock Certificates), hereinafter called Stockholder, who, having been first duty sworn by the undersigned Notary Public, deposes and says: 1. Stockholder resides at ____________________________________________________________ ______________________________________________________________________________ _________________________________________ (street address, city, county, state, zip code) . 2. Stockholder is the legal and beneficial owner of _________ ( number) shares of the (i.e., common) _____________________ stock of ________________________________________________ (name of corporation) represented by the certificates described as follows: Number Date Registered Name in Corporation’s Records ____________ ____________ _______________________________________________ ____________ ____________ _______________________________________________ ____________ ____________ _______________________________________________ 3. The above certificates were not endorsed. 4. Neither the above certificates nor the rights of Stockholder in the certificates have, in whole or in part, been assigned, transferred, hypothecated, pledged, or otherwise disposed of. 5. Stockholder is entitled to the full and exclusive possession of the above certificates. 6. The circumstances concerning the missing certificates and the efforts made to locate them are as follows: (describe in detail) _____________________________________________________________ _____________________________________________________________________________________ ____________________________________________________________________________________. 7. This affidavit is made for the purpose of inducing ______________________________________ ___________________________ (name of corporation) to issue new certificates in lieu of those missing (e.g., due to theft or destruction) _____________________________________________________ , and Stockholder agrees to immediately surrender to ______________________________________________ (name of corporation) said certificates should they later come into Stockholder ’s possession or control. _____________________________________________ _____________________________________________ (Printed Name & Signature of Stockholder) SWORN to and subscribed before me, this the _____ day of ___________________________________, 20_____. _______________________________________ NOTARY PUBLIC My Commission Expires: _________________________