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.






 Affidavit For Lost Stolen Destroyed Stock Certificate

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