AFFIDAVIT OF LOSS OF SHARE CERTIFICATE
__________________________________, being first duly sworn, deposes and says:
1. I am the sole and absolute owner of _____________________ shares of, ________ which shares are represented by share certificate number ______________.
2. I have not sold, transferred, assigned or hypothecated said shares or in any other way divested myself or been divested of the ownership thereof.
3. Share certificate number _____________ has been lost, destroyed, or misplaced, through inadvertence or otherwise, and after making a diligent search of my records, I am unable to locate it.
4. I make this affidavit for the purpose of inducing the issuance of credit of the face amount of same without surrender thereof for cancellation.
_______________________________ Signature
Sworn to and subscribed before me, this the _______ day of __________ , (year)____
My Commission Expires: ______________________________
______________________________ Notary Public