Affidavit lost, stolen, destroyed Stock Certificate


State of ______________________
County of _____________________

I,     [name]    , being duly sworn, state:

That I reside at   [address]   ,   [city]    ,  [state]

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.

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

That the circumstances surrounding the    [loss, or theft,
or destruction, or disappearance]   of said certificates
and my attempt to locate them are as follows:

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.


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