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STATE OF State
COUNTY OF County
Name of Street address , City , State , ZIP Code , being duly sworn, does hereby swear and affirm as follows:
For self / For a business
1. I am of legal age, and am an authorized officer, representative, or agent of Name , which is the sole legal and beneficial owner (the "Shareholder") of Shares shares of Class of stock stock, $ Amount par value, of Name , a(n) State corporation (the "Company"), represented by certificate number(s) Number(s) (the "Original Certificate(s)"), issued on Date by the Company in the name of the Shareholder.Lost / Stolen / Destroyed
2. The Original Certificate(s) have been lost .
3. The Shareholder has made the following efforts to locate the Original Certificate(s) : Description . Yes / No
4. The Original Certificate(s) were not endorsed .
5. None of the Original Certificate(s), or the Shareholder's rights in them, have, in whole or in part, been assigned, transferred, hypothecated, pledged, gifted, or otherwise disposed of in any manner whatsoever.
6. The Shareholder is entitled to the full and exclusive possession of the Original Certificate(s), and no other person or entity has any interest in the Original Certificate(s) or the proceeds from those.
7. If the Shareholder ever locates the Original Certificate(s), or if they are otherwise returned to the Shareholder, the Shareholder agrees that such Original Certificate(s) have no value and that it will surrender those recovered Original Certificate(s) to the Company immediately and without consideration for cancellation.
8. The Shareholder hereby requests and is making this affidavit for the purpose of requesting the Company to issue new or duplicate stock certificates in substitution for the Original Certificate(s).
SIGNATURE PAGE FOLLOWS
The Shareholder is signing this affidavit on the date set forth below.
Date: ____________________
______________________________________________
Signature of Signer Name
STATE OF Aff State
COUNTY OF Aff County
Subscribed and sworn to before me this ____ day of _______, 20___, at _______, ____________.
______________________________________________
Signature of Notary Public
Name of Notary Public: ______________________________________________ (SEAL)
Notary Public, State of Aff State
My commission expires: ____________________