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
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.