This is an affidavit stating that a shareholder has lost or misplaced his or her stock
certificates and wants to request replacements. This document officially states that the
shareholder has lost the certificate, and has not transferred it to someone else. It
should be sent to the company that issued the original document so they can cancel the
original numbered stock certificate and replace it with a new one.
I. AFFIDAVIT OF LOST STOCK CERTIFICATE
I, ______________________ of the_______________, on this______ , day
MAKE OATH AND SAY AS FOLLOWS:
1. 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.
2. That I warrant and represent that the said stock certificate has not been assigned,
hypothecated, sold, pledged or transferred.
3. That the circumstances surrounding loss of said certificates and my attempt to locate them are
4. As an inducement for the Corporation issuing a duplicate replacement certificate, the
undersigned agrees to fully indemnify and save harmless the Corporation for any claim of
ownership by any asserted owner or holder of the said shares.
I hereby agree to surrender to Corporation the original certificates issued to me should they
hereafter come into my possession or control.
© Copyright 2011 Docstoc Inc. registered document proprietary, copy not 2
(FOR NOTARY PUBLIC)
STATE OF _____________________ COUNTY OF ______________________
In _______________, on the _____________ day of ____________, 200x,
before me, a Notary Public in and for the above state and county, personally
appeared (NAME OF AFFIANT), known to me or proved to be the person
named in and who executed the foregoing instrument, and being first duly
sworn, such person acknowledged that he or she executed said instrument for
the purposes therein contained as his or her free and voluntary act and deed.
Type of Identification Produced: _________________________
Affiant is / is not personally known to me ( )
My Commission Expires: ________________
© Copyright 2011 Docstoc Inc. registered document proprietary, copy not 3