Stock Certificates Forms - PDF by iik16908

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									  LOST CERTIFICATES – DOCUMENTS TO BE FILED AND INSTRUCTIONS
Prompt delivery of completed forms, with fees as specified below, will help to expedite the replacement process.

INSTRUCTIONS: To process requests for the replacement of lost or stolen stock certificates, First American Stock
Transfer (as transfer agent), the Issuer and the Securities and Exchange Commission require certain documents to be filed
with the transfer agent. Please print the forms from this site for your use. (Some data may be pre-entered by you.)

1. X-17F-1A FORM – MISSING/LOST/STOLEN/COUNTERFEIT SECURITIES REPORT: This attached form must
    be fully completed. The required information may be entered onto the form before printing it from this site. The form must be
    signed in two places by the shareholder(s) or the shareholder(s) legal representative, with the signature(s) notarized. Upon receipt
    by the transfer agent of the X-17F-1A Form, a “lost certificate/stop transfer” order will be placed against the certificate(s), and the
    certificates(s) will be reported to the Securities Information Center as lost.

In order to assist shareholders in arranging for the required lost instrument bond, we have adopted, as a convenience, a Blanket Lost
Instrument Bond through XL Specialty Insurance Company and Special Risk Managers of America, Inc. The premium under this
blanket bond is generally lower than the standard premium charged for individual bonds.* The premium is 2% of the market value of
the securities (4% for foreign shareholders), subject to a minimum premium of $25.00. (The market value is calculated as the value on
the day First American Stock Transfer Company received report of the loss and put a “Stop Transfer” order on the certificate.) To
replace your certificate(s) under this Blanket Lost Security Bond, please complete the forms on this site described as:

2. “AFFIDAVIT FOR LOSS” – EXHIBIT B: Complete this form in triplicate (3 originals) – signed by the shareholder(s) or
    the shareholder(s) legal representative, and notarized. Submit all copies to First American Stock Transfer.

3. “AGREEMENT OF INDEMNITY” – EXHIBIT C:                                Complete this form in triplicate (3 originals) – signed by the
    shareholder(s) or the shareholder(s) legal representative, and notarized. Submit all copies to First American Stock Transfer.

4. If the value of the lost securities EXCEEDS $50,000.00, the following form must also be provided:

    “APPLICATION FOR LOST INSTRUMENT BOND” – EXHIBIT D: Complete this form in triplicate (3 originals) –
    signed by the shareholder(s) or the shareholder(s) legal representative, and notarized. Submit all copies to First American Stock
    Transfer. Because Special Risk Managers of America may need to verify assets listed on this Application, they also require:
         • a recent copy of bank and/or brokerage statements showing the assets listed, or
         • a letter of authorization permitting Special Risk Managers of America to
             contact the bank and/or broker to confirm the assets as described therein.
      If the Application is approved by Special Risk Managers of America, First American Stock Transfer will then receive
      an Assumption Certificate authorizing the replacement of the lost certificate(s).

5. If the registered owner is a corporation, you must include a copy of the company’s corporate resolution, authorizing
      the officer who is signing these documents to sign on behalf of the corporation.

6. FEES (in US dollars) - CHECKS PAYABLE TO:

    1.     First American Stock Transfer (fee for X-17 Filing and Certificate Replacement): $ 50.00 per certificate
    2.     Special Risk Managers of America: 2% of securities market value (4% for foreign holders) subject to minimum of
           $25.00

              IMPORTANT NOTE: If the premium amount is over $2,000.00, a money order or wire-transfer must be used in lieu of a check.
                              Contact First American Stock Transfer for wire-transfer instructions for Special Risk Managers of America

7. Send all completed documents – and both checks – together in one package to:
                      First American Stock Transfer                                    Phone: (602) 485-1346
                      706 East Bell Road, Suite 202
                      Phoenix, AZ 85022
         * Please Note: You are not required to utilize the above lost instrument indemnity arrangement with Special Risk Managers of America. You
         may furnish a lost instrument indemnity bond from an acceptable surety company of your own choosing. However, the surety company must be
         authorized to do business in the State of Arizona, and must first be acceptable to First American Stock Transfer. The original indemnity bond,
         issued in favor of First American Stock Transfer, must first be received in order to replace the lost certificate(s).
                                                                                                                                Revised - 7:06 AM 4/4/2007
                                               X-17F-1A FORM
                                   MISSING / LOST / STOLEN / COUNTERFEIT
                                             SECURITIES REPORT
Please type or print clearly

1. Reporting Institution:                      Name:       First American Stock Transfer, Inc.

                                               Address:   706 E Bell Rd, Suite 202

                                                          Phoenix, AZ    85022

                                               Attention: Phil Young

 (602)485-1346                     Fins/Access Code 4 0 9 3 1 8 / __ __ __
Telephone Number

2. Type of Report:              ___ Loss        ___ Recovery       ___ Update      ___ Escheated
                                ___ Stolen      ___ Counterfeit    ___ Other ______________________

3. Date of Loss/Recovery: ___/___/___

4. Type of Loss:   ___ Mail               ___ Delivery      ___ On-sight     ___ Other
_______________________

5. Type of Security:              ___ Common     ___ Preferred    ___ Corporate Bond
                                  ___ Municipal Bond ___ Government Agency   ___ Other
___________________

6. Name of Issuer:             _________________________________________________________

7. Interest rate:              0.00%
                               _____________           8. Maturity Date ___/___/______

9. CUSIP Number           ___ ___ ___ ___ ___ ___ ___ ___ ___

10. Bearer/Name of Registered Holder:
__________________________________________________________

11. Certificate/Serial Numbers                  12. Denominations/Shares 13. Issue Date
     ________________________                       _____________________       ___/___/________
     ________________________                       _____________________       ___/___/________
     ________________________                       _____________________       ___/___/________
     ________________________                       _____________________       ___/___/________
     ________________________                       _____________________       ___/___/________
     ________________________                       _____________________       ___/___/________
     ________________________                       _____________________       ___/___/________

14. Additional Pages Attached: ___ 15. Total Market/Face Value $ ________________

16. Counterfeit ________________________________________________________________

17. Criminality Indicated ___18. Reports filed with: a. FBI ___ b. Police ___

20. Transfer/Pay Agent: First American Stock Transfer, Inc.

21. Insurance Co. _______________________________________________________________

22. ________________________________                                        23.   ___/___/___
Authorized Signature                                              Date
                              Stock Certificate Replacement Request



I, ______________________________ do state under oath that I have lost or am in non-receipt of these securities and
request First American Stock Transfer, Inc. to replace said shares. I understand there is a $50.00 fee for this service.




______________________________________________
Signed and have it Notarized (Not medallion Guaranteed)




Notary Stamp here
                                                                         Special Risk Managers of America, Inc.
                                                                                        211 North Finley Avenue
                                                                                        Bernardsville, NJ 07924



AFFIDAVIT FOR LOSS – EXHIBIT B




The undersigned (hereinafter called “Deponent”), being duly sworn, deposes and says that:


(1) Deponent is an adult whose mailing address is



   and is the owner of or is acting in a representative or fiduciary capacity with respect to certain securities
   (describe type of security, identification number, and number of shares or face value):



   issued by:



   (hereinafter called the “Issuing Corporation) and registered in the name of:



(2) Deponent further says the aforesaid security or securities (hereinafter called the “original”, whether one
    or more) have been lost, stolen, destroyed or misplaced under the following circumstances:



(3) That said Original (WAS/WAS NOT) (choose one) endorsed. (If endorsed, describe form of
    endorsement and state whether signature was guaranteed.)



(4) Deponent has made or cause to be made diligent search for Original, and has been unable to find or
    recover same, and the Deponent was the unconditional owner of Original at the time of loss, and is
    entitled to the full and exclusive possession thereof, that neither the Original nor the rights of Deponent
    therein have, in whole or in part, been assigned, transferred, hypothecated, pledged or otherwise
    disposed of, in any manner whatsoever, and that no person, firm or corporation other than deponent has
    any right, title, claim, equity or interest in, to or respecting Original or the proceeds thereof, except as
    may be set forth in Statement (5) following:




                                                       1
(5) If Deponent’s interest in the Original is in a representative or fiduciary capacity, indicate below the
    designation of such capacity, i.e., Administrator, Executor, etc., and the title of the estate, as follows:

   Deponent is ____________________ of the estate of _____________________________________
       (Specify names of any other persons having and interest in the Original. List them below and
       indicate the nature of the interest, such as heir, legatee, etc.)

                            NAME                                            INTEREST




   (EACH HEIR, LEGATEE, ETC., HAVING AN INTEREST IN THE ORIGINAL MUST EXECUTE AN
   AGREEMENT OF INDEMNITY, EXHIBIT “C”.)

(6) Deponent makes this affidavit for the purpose of requesting and inducing the Issuing Corporation and its agents
    to issue new securities in substitution for the Original and XL Specialty Insurance Company to assume liability
    in respect thereof under its Indemnity Bond, #_______________.


(7) Deponent agress that if said Original should ever come into Deponent’s hands, custody or power, Deponent will
    immediately and without consideration surrender the Original to Issuing Corporation, its transfer agents,
    subscription agents, trustees, or Special Risk Managers of America, Inc. for cancellation.


(8) Signed, sealed and dated : _________________________, _________.



Sworn to and subscribed before me this ____________day of ____________________, ________.


___________________________________                               ___________________________________
           Notary Public                                                 Signature of Deponent
        (Affix Notarial Seal)

My Commission expires:



Sworn to and subscribed before me this ____________day of _____________________, _________.


___________________________________                               ____________________________________
          Notary Public                                                   Signature of Deponent
        (Affix Notarial Seal)

My Commission expires:


Bond #




                                                        2
                                                                               Special Risk Managers of America, Inc.
                                                                                              211 North Finley Avenue
                                                                                              Bernardsville, NJ 07924

AGREEMENT OF INDEMNITY – EXHIBIT C


KNOW ALL MEN BY THESE PRESENTS:

(1) WHEREAS, an Affidavit of Loss was made by


   with the respect to certain securities (describe type of security, identification number, and number of shares or face value):




   issued by:


   (hereinafter called the “Issuing Corporation”) and registered in the name of:



(2) WHEREAS, the aforesaid security or securities (hereinafter called the “Original”, whether one or more) have been lost,
    stolen, destroyed or misplaced.

(3) NOW, THEREFORE, in consideration of XL Specialty Insurance Company assuming liability or liability attaching under
    its Indemnity Bond in favor of the Issuing Corporation and its agents, the undersigned (jointly and severally, if more than
    one) hereby agree at all times to indemnify and save harmless XL Specialty Insurance Company from and against any and
    all liabilities, losses, damages, judgments, costs, charges, counsel, fees and expense of every nature and character which
    they may sustain or incur by reason or on account of assuming liability attaching under its Indemnity Bond, #               .

(4) Signed, sealed and dated:                               ,                      .

   (IF THE INDEMNITOR IS AN HEIR AS WELL AS FIDUCIARY, HE/SHE MUST SIGN IN AN INDIVIDUAL
   CAPACITY, WRITING “INDIVIDUALLY UNDER HIS/HER SIGNATURE.)

Sworn to and subscribed before me this             day of                                        ,              .


          Notary Public                                                                               INDEMNITOR
       (Affix Notarial Seal)
                                                                                       Address

My Commission expires:


Sworn to and subscribed before me this             day of                                        ,              .


           Notary Public                                                                              INDEMNITOR
        (Affix Notarial Seal)
                                                                                   Address:

My Commission expires:
                                                                                Special Risk Managers of America, Inc.
                                                                                  914 Mt. Kemble Ave.
                                                                                Morristown, N. J. 07960

                         Application for Lost Instrument Bond - Exhibit D
Applicant ____________________________________________ Social Security or Tax ID No. _______________________

Residence Address _____________________________________________________________________________________

Business Address ______________________________________________________________________________________

Occupation or business _________________________________________________________________________________

Phone #’s ____________________________________________________________________________________________

Fax #’s ______________________________________________________________________________________________

E-Mail Address ________________________________________________________________________________________




                                     (Attach Transfer Agent’s replacement requirements)

1. Description of Lost Securities/Instrument (certificate/check number, issue date, number of shares, value):

   __________________________________________________________________________________________________

   __________________________________________________________________________________________________

2. Issuing company? ___________________________________________________________________________________

3. Registered in whose name? ___________________________________________________________________________

4. (a) Have you ever signed the securities or executed a stock power for their transfer? Yes ____ No ____
   (b) Have the securities been otherwise endorsed, pledged or accompanied by a power of attorney? Yes ____ No ____
   If your answer is Yes to (a) or (b) above, give details. ______________________________________________________

   __________________________________________________________________________________________________

5. Do you have absolute title, free of any claims or liens? Yes ____ No ____

   If No, give full details. ________________________________________________________________________________

6. When were the securities last in your possession and how were they lost or destroyed? ___________________________

    _________________________________________________________________________________________________

7. Who did you notify of the Loss?   Transfer Agent: Yes ___ No ___      Police: Yes ___ No ___    Other: Yes ___ No ___

   Give details ________________________________________________________________________________________
                                 FINANCIAL STATEMENT as of _______________________, _______.

     Cash in Bank ___________________________________                        Bank Loan ___________________________________
     Securities (Market) ______________________________                      Borrowed on Securities _________________________
     Accounts Receivable _____________________________                       Accounts Payable _____________________________
     Notes Receivable _______________________________                        Notes Payable ________________________________
     Real Estate ____________________________________                        Mortgage of Real Estate ________________________
     Cash Value of Life Ins. ___________________________                     Other Liabilities _______________________________
     Other assets ___________________________________                                         _______________________________
          TOTAL ___________________________________                               TOTAL _________________________________

     Have you ever filed for bankruptcy? Yes ____ No ____     If Yes, what year filed? ______
     Describe the outcome (dismissal or discharge). __________________________________________________________

     Are there any judgments or legal proceedings against you? Yes ____ No ____
     If Yes, describe. ___________________________________________________________________________________



                                          List financial references, including bank/brokerage firm:

          Name of firm                             Address                                   Contact                        Phone No.

     _________________________________________________________________________________________________

     _________________________________________________________________________________________________

     _________________________________________________________________________________________________

Indemnity Agreement
The undersigned applicant and indemnitors (hereinafter called undersigned) hereby certify and represent that the information and
statements contained in this application are true and correct and are made to induce XL Specialty Insurance Company, Greenwich Insurance
Company, CGU Insurance Company, General Accident Insurance Company, or Commercial Union Insurance Company, and any of their
subsidiary, associated or affiliated companies, their successors and assigns (hereinafter called Surety) to issue the bond(s) applied for herein.
In consideration of the issuance of the bond(s) herein applied for, or any bond(s) in substitution for or in succession of said bond(s) or any
increase or extension of time of the said bond(s), and for other good and valuable consideration, the receipt of which is hereby
acknowledged, the undersigned jointly and severally covenant and agree:

1.   To pay to the Surety such premium as the Surety shall charge upon execution of the bond(s) and annually in advance thereafter until
     such time as the Surety’s liability under the bond(s) is terminated;
2.   That the Surety may decline to execute or provide any bond(s) applied for and may cancel or terminate any bond(s) executed by the
     Surety without incurring any liability whatsoever to the undersigned;
3.   To exonerate, indemnify and keep indemnified the Surety from and against all demands, claims, losses, costs, damages, and expenses
     including attorney’s fees which the Surety may sustain or incur by reason of the issuance of the bond(s) or undersigned'’ failure to
     perform or comply with any of the provisions, of this agreement or the obtaining of a release of or evidence of termination under such
     bond(s);
4.   In order to exonerate and indemnify the Surety, to place the Surety in funds immediately when requested to do so in order to meet and
     satisfy any claim or demand made upon the Surety under the bond(s) before the Surety shall be required to make payment under the
     bond(s);
5.   To furnish the Surety with satisfactory and conclusive evidence that there is no further liability on the bond(s);
6.   That the Surety shall have the exclusive right to adjust, settle or compromise any claim under such bond(s) and that the voucher or other
     evidence showing payment by the Surety in good faith by reason of such bond(s) or any renewal, extension or substitution thereof shall
     be conclusive and in any event prima facie evidence of such payment and the propriety thereof and the liability of the undersigned
     therefore to the Surety;
7.   That undersigned upon the demand of Surety shall immediately arrange for the joint custody and control by Surety of all cash, securities,
     negotiable instruments and other real or personal property as the Surety may require, belonging to an estate or trust which is the subject
     of the bond(s) or which assets are under the control or management of the undersigned and for which undersigned may be required by
     law to render an accounting;
8.   This Agreement shall constitute a Security Agreement to Surety and also a Financing Statement, both in accordance with the provisions of
     the Uniform Commercial Code of every jurisdiction wherein such Code is in effect, but the filing or recording of this Agreement shall be
     solely at the option of Surety and the failure to do so shall not release or impair any of the obligations of the Undersigned under this
     Agreement or otherwise arising, nor shall such failure be in any manner in derogation of the rights of Surety under this Agreement or
     otherwise.
                                              FRAUD WARNINGS

NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent claim for
payment for a loss or benefit or knowingly presents false information in an application for insurance is guilty of
a crime and may be subject to fines and confinement in prison.

NOTICE TO CALIFORNIA APPLICANTS: Pursuant to California Insurance Law, Sec. 1623, this application
for insurance is being submitted by an insurance broker who is acting on behalf of an insured.

NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding or attempting to defraud the
company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy
holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to
the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO D.C. APPLICANTS: WARNING: It is a crime to provide false or misleading information to an
insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or
fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim
was provided by the applicant.

NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or
deceive any insurance company files a statement of claim or an application containing any false, incomplete,
or misleading information is guilty of a felony of the third degree.

NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that
presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment
or both.

NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance containing any materially false
information or conceals for the purpose of misleading, information concerning any fact material thereto
commits a fraudulent insurance act, which is a crime.

NOTICE TO LOUISIANA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of
a crime and may be subject to fines and confinement in prison.

NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for purposes of defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.

NOTICE TO MARYLAND APPLICANTS: Any person who, with intent to defraud or knowing that he is
facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive
statement may be guilty of insurance fraud.

NOTICE TO MINNESOTA APPLICANTS: A person who submits an application or files a claim with intent to
defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on
an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim
for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty
of a crime and may be subject to civil fines and criminal penalties.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or statement of claim containing any
materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime, and shall be also subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he is facilitating
a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is
guilty of insurance fraud.

NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false,
incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON APPLICANTS: Any person who makes an intentional misstatement that is material to
the risk may be found guilty of insurance fraud by a court of law.

NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or statement of claim containing any
materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal
and civil penalties.

NOTICE TO TENNESSEE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.

NOTICE TO TEXAS APPLICANTS: Any person who makes an intentional misstatement that is material to
the risk may be found guilty of insurance fraud by a court of law.

NOTICE TO VIRGINIA APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties include
imprisonment, fines and denial of insurance benefits.

NOTICE TO ALL OTHER STATE APPLICANTS: Any person who knowingly includes any false or misleading
information on an application for an insurance policy is subject to criminal and civil penalties.

THE APPLICANT REPRESENTS THAT THE ABOVE STATEMENTS AND FACTS ARE TRUE AND THAT
NO MATERIAL FACTS HAVE BEEN SUPPRESSED OR MISSTATED.

COMPLETION OF THIS FORM DOES NOT BIND COVERAGE. APPLICANT’S ACCEPTANCE OF THE
COMPANY’S QUOTATION IS REQUIRED PRIOR TO BINDING COVERAGE AND POLICY ISSUANCE.

ALL WRITTEN STATEMENTS AND MATERIALS FURNISHED TO THE COMPANY IN CONJUNCTION
WITH THIS APPLICATION ARE HEREBY INCORPORATED BY REFERENCE INTO THIS APPLICATION
AND MADE A PART HEREOF.
Signed, sealed and dated this __________________ of _____________________________, __________.

If applicant is an individual:

X_____________________________________________                            Print Name: ___________________________________________
 Individually

X_____________________________________________                            Print Name: ___________________________________________
 Individually

If applicant is an Estate or Corporation:

X _____________________________________________                           Print Name: __________________________________________

                                                                          Designation or Title: ____________________________________

                                    ALL SIGNATURES MUST BE ACKNOWLEDGED BY A NOTARY
On this _______ day of ____________________, _______, before me personally appeared _______________________________________,
to me known and known to me to be the individual(s) described in and who executed the foregoing agreement and acknowledged that
he/she/they executed the same for the purposes, considerations and uses therein set forth as he/she/they free and voluntary act and deed.
   IN WITNESS WHEREOF, I have hereunto set my hand and affixed my OFFICIAL SEAL, the day and year first above written.

____________________________________________________
Notary Public
Commission expires: ___________________________________
Seal:

								
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