AFFIDAVIT OF LOST STOCK CERTIFICATE AND
STATE OF: __________)
COUNTY OF :________)
_________________, [Insert Name] (the “Holder”), of __________________________
[Insert Address] being duly sworn, does hereby swear and affirm as follows:
1) The Holder is of legal age and is the sole legal and beneficial owner of
_______________ [Number] shares of _____ [class] stock, ________ par value,
of ______________, a ______ [corporation][limited liability company][etc.] (the
“Company”), represented by Certificate Number[s]
_________________________ (the “Original Certificate[s]”), issued on
__________ [date] by the Company in the name of the Holder.
2) The Original Certificate[s] has/have been [lost] [stolen] [destroyed].
3) The Original Certificate[s] was/were [not endorsed] [endorsed as follows:
4) None of the Original Certificate[s], or any of the Holder’s rights therein, have, in
whole or in part, been assigned, transferred, hypothecated, pledged, gifted, or
otherwise disposed of in any manner whatsoever.
5) The Holder is entitled to the full and exclusive possession of the Original
Certificate[s], and no other person or entity has any right, title, claim, equity, or
interest in, to, or respecting the Original Certificate[s] or the proceeds thereof.
6) The Holder has made the following efforts to locate the Original Certificate[s]
[The destruction of the Original Certificate[s] occurred as follows]:
7) If the Holder ever locates the Original Certificate[s], or if they are otherwise
returned to the Holder, the Holder agrees that such Original Certificate[s]
has/have no value and that it will surrender those recovered Original Certificate[s]
to the Company immediately and without consideration for cancellation.
Affidavit of Lost Stock Certificate and Indemnity Agreement
8) The Holder hereby requests and is making this affidavit (the “Affidavit”) for the
purpose of requesting the Company to issue new or duplicate stock certificates in
substitution for the Original Certificate[s].
9) In consideration of the foregoing, the Holder, for itself, its heirs, legal
representatives, successors, and assigns, agrees to:
a. Release and forever discharge the Company, its legal representatives,
successors, and assigns from any and all claims, suits, and/or causes of
action that the Holder may have against the Company in any way relating
to or arising out of the Original Certificate[s] and/or the Company’s
compliance with the request of the Holder in this Affidavit regarding these
shares of the Company’s stock; and
b. Indemnify, hold free and harmless, and protect the Company, its legal
representatives, successors, and assigns including, without limitation, its
registrar and transfer agent, from any and all losses, damages, liabilities,
costs, charges, counsel fees, and/or expenses incurred in connection with
or in any way relating to or arising out of:
i. The issuance and delivery of [a] new certificate[s];
ii. Any payment, transfer, delivery, exchange, or other act made or
done with respect to the Original Ce