AFFIDAVIT RE: SHARES

COUNTRY OF _______________

TO WIT:
)
)
)
)
)
IN THE MATTER OF ________ SHARES
(THE SHARES) IN THE CAPITAL OF
BLUE PLANET ENVIRONMENTAL
INC. (THE CORPORATION)


I, ___________________, of the ________ of _______________, in the
_____________ of _______________, MAKE OATH AND SAY THAT:

1. I am the registered owner of the Shares and such Shares were issued/purchased by
me on or about ____________, 20___.

2. I have not sold, transferred, assigned, pledged, hypothecated or otherwise
encumbered the Shares, nor have I in any way divested myself or been divested of the ownership
thereof.

3. I do not have a share certificate that evidences the Shares and one cannot be
produced.

4. I hereby indemnify and save the Corporation harmless from any and all costs,
damages and liabilities which the Corporation may incur as a result of the non delivery to you of
a certificate that evidences the Shares and the issuance of a replacement share certificate, and I
hereby undertake that should a certificate representing all or a portion of the Shares come into
my possession, I will deliver it promptly to the Corporation for cancellation.

5. Attached as Schedule A is a true and correct copy of a notarized brokerage
statement confirming/evidencing my ownership of the Shares.



SWORN BEFORE me at the

of

, in the

of

,
___________ of ______________, this

day of

, 201

.



)
)
)
)
)
)
)

A Commissioner, etc. )



#2236093 v1 | 4063279