Affidavit of Lost Stock Certificate Form

Affidavit of Lost Stock Certificate is a legal document intended to declare the incapacity to produce upon the loss of the stock certificates. Affidavit maker subscribes and swears on oath under the penalties of perjury before the Notary Public of the state.

The maker also undertakes that the said stock certificate stolen, lost, or destroyed are irreversibly lost and these are not mortgaged or pledged anywhere at any known sources to the maker. The purpose of making and submitting Affidavit of Lost Stock Certificate is to request the issuance of the duplicate or new stock certificates from the original issuing authorities and/or entity. Furthermore, the maker of the affidavit undertakes to return original stock certificates upon finding them in whatsoever circumstances and manner.

Before You Begin

  1. Furnish registered owner’s name as it appeared on the stolen, lost, or destroyed stock certificates.
  2. Provide information about the number of shares and the name of the issuer in the spaces provided for the same to sanctify the same in the Affidavit of Lost Stock Certificate.
  3. Furnish share certificate numbers if possible.
  4. Notarization of Affidavit of Lost Stock Certificate is necessary before the Notary Public of the State for its execution and legal validity.
  5. Compete all fields of Affidavit of Lost Stock Certificate legibly and make copies before submitting the notarized document to the issuer of the stock certificates along with the request for issuance of new or duplicate certificates as applicable.

The foremost portion of the Affidavit of Lost Stock Certificate has space for inserting the name of the county followed by the name of the state.

Enter your name on the subsequent line followed by the residential address, name of the city, state, and zip code.

Describe in details about the stolen, lost, or destroyed stock certificates and provide the stock certificate numbers if available. The next line requires inputting your legal name as appears on the stock certificates to specify the registered owner’s name. Furnish the name of issuing entity followed by entering the number of shares.

Section 2 requires input of your name to declare your ownership of the stolen, lost, or destroyed stock certificates and the subject of the affidavit. Your signature is required below the declaration and undertaking in subsequent sections from 3 to 5.

The last portion of the Affidavit of Lost Stock Certificate has space for notarization before the Notary Public of the concerned state. Inputs required are date in the prescribed format, signature and seal of the Notary Public, and date of expiry of the commission.

Affidavit of Lost Stock Certificate

Text Version of This Form

Affidavit of Lost Stock Certificate

State of _______________
County of _____________

___________________, being first duly sworn on oath deposes and says that he/she is an adult and resides at _____________________.

1. The certificate(s) representing the following described shares of stock has been lost, stolen or destroyed: ____________________________.

The registered owner’s exact name as it appears on the original certificate is ______________________ .

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.

5.  If such new or duplicate certificate(s) is so issued, countersigned and registered, or such payment, delivery, exchange or credit is made in respect of such original(s), then it is understood and Affiant hereby agrees that if said lost certificate comes into Affiant’s control or custody, the recovered stock certificate will be delivered to the issuer or, at issuer’s request, to issuer’s Transfer Agent, for the purpose of cancellation.

Owner of Stock

Subscribed and sworn to before me this _________day of ____________, 20______.

Notary Public

My commission expires:______________________