| | Affidavit For Lost, Stolen, Destroyed Stock Certificate
State of [State]
County of [County]
I, [name], being duly sworn, state:
That I reside at [Complete address], [city], [state]
That I am the legal and beneficial owner of [numerical quantity]
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.
That I have not assigned, hypothecated, pledged, or in any
other way disposed of either the stock certificates or my
rights as a stockholder, in whole or in part.
That I am entitled to full and exclusive possession of said
certificates.
That the circumstances surrounding the [loss, or theft,
or destruction, or disappearance] of said certificates
and my attempt to locate them are as follows:
[brief description]
That the purpose of preparing this affidavit is to induce
[corporation] to issue new certificates to replace those
that have been [lost, stolen, destroyed].
I hereby agree to surrender to [corporation] the
original certificates issued to me should they hereafter
come into my possession or control.
Dated:
______________________________________
[Clearly Print Name After Signature]
Dated:
Witness: ______________________________
[clearly print name after signature]
Sworn and subscribed before me this [numerical] day of [Month],
[Year] A.D.
Notary Public: ______________________________
[clearly print name after signature]
My Commission expires: [Date] |
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