State of _______________ District of _____________ ___________________, being first duly sworn on oath deposes and says that ___ is an adult and resides at _____________________.
1. The certificate(s) representing the following described shares of stock has been lost, stolen or destroyed: ____________________________. Registered owner’s exact name as it appears on the original certificate: Issuer’s name: Number of shares:
2. The above-described stock is solely owned by ________________.
3. That Affiant has made or caused to be made a diligent search for said securities and has been unable to find or recover same. Neither said securities nor any interest therein has been sold, assigned, endorsed, pawned, pledged for any bank or brokerage loan or otherwise, or disposed of in any manner by or on behalf of said owner. Neither said owner nor anyone on said owner’s behalf has signed any power of attorney, any stock power, or other assignment or authorization respecting the same which is now outstanding and in force. No person, firm or corporation has any right, title, claim, equity, or interest in, to, or respecting said securities, excepting the sole owner above named.
4. That this affidavit is made for the purpose of inducing the issuance of a new or duplicate certificate in substitution of or in exchange for said lost, stolen or destroyed certificate without requiring the surrender of the original, or the payment, delivery, exchange, or credit in respect of such original without such surrender, and/or inducing to issue an indemnity bond….
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