AFFIDAVIT OF LOST STOCK CERTIFICATE
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]: