Affidavit of Lost Stolen or Destroyed Stock Certificate Form

Download and Use this Affidavit form if you have Lost your Stock Certificate or if it has been stolen or Destroyed.

Affidavit of Lost Stolen or Destroyed Stock Certificate

Text Version of This Form

Affidavit of Lost, Stolen or Destroyed Stock Certificate

State of ______________________
County of _____________________

I,_______________, being duly sworn, state:

That I reside at _______________,_______________, _______________ .

That I am the legal and beneficial owner of _______________ shares of the common/preferred stock of _______________ represented by certificates described as follows:

Number             Date                                        Registered Name
_______          _________________       ___________________
_______          _________________       ___________________

That said certificates were/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: _____________________________________________________

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:_____________ , 20___


Maker of Affidavit

Subscribed and sworn to before me this __ day of ________, 20__.

Notary Public

My Commission Expires on: ______________