Affidavit for Lost- Stolen- Destroyed Stock Certificate

AFFIDAVIT FOR LOST, STOLEN, DESTROYED STOCK CERTIFICATE
State of ______________________

County of _____________________
I, (name) , being duly sworn, state:
That I reside at (address) , (city) , (state)
That I am the legal and beneficial owner of (number)

shares of the (specify class) stock of (corporation)

represented by certificates described as follows:
Number Date Registered Name


That said certificates (were or were not) endorsed.
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.
That I am entitled to full and exclusive possession of said

certificates.
That the circumstances surrounding the (loss, or theft,

or destruction, or disappearance) of said certificates

and my attempt to locate them are as follows:


That the purpose of preparing this affidavit is to induce

(corporation) to issue new certificates to replace those

that have been (lost, stolen, destroyed).
I hereby agree to surrender to (corporation) the

original certificates issued to me should they hereafter

come into my possession or control.
Dated:_____________________

____________________

(Signature)

(Jurat)