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Text File  |  1991-06-08  |  1.4 KB  |  46 lines
  1.  
  2. AFFIDAVIT FOR LOST, STOLEN, DESTROYED STOCK CERTIFICATE
  3.  
  4. State of ______________________
  5. County of _____________________
  6.  
  7. I,     [name]    , being duly sworn, state:
  8.  
  9. That I reside at   [address]   ,   [city]    ,  [state]
  10.  
  11. That I am the legal and beneficial owner of    [number]
  12. shares of the    [specify class] stock of [corporation]
  13. represented by certificates described as follows:
  14.  
  15. Number                 Date                Registered Name
  16.  
  17.  
  18. That said certificates     [were or were not]    endorsed.
  19.  
  20. That I have not assigned, hypothecated, pledged, or in any
  21. other way disposed of either the stock certificates or my
  22. rights as a stockholder, in whole or in part.
  23.  
  24. That I am entitled to full and exclusive possession of said
  25. certificates.
  26.  
  27. That the circumstances surrounding the    [loss, or theft,
  28. or destruction, or disappearance]   of said certificates
  29. and my attempt to locate them are as follows:
  30.  
  31.  
  32. That the purpose of preparing this affidavit is to induce
  33. [corporation]   to issue new certificates to replace those
  34. that have been    [lost, stolen, destroyed].
  35.  
  36. I hereby agree to surrender to     [corporation]     the
  37. original certificates issued to me should they hereafter
  38. come into my possession or control.
  39.  
  40. Dated:_____________________
  41.                                   ____________________
  42.                                      [Signature]
  43. [Jurat]
  44.  
  45.  
  46.