Affidavit of Lost Stock

WHEREAS, I, {name} am the owner of {number} shares of {corporation name}

stock.

WHEREAS, despite my best efforts and searches, I am unable to locate the

stock certificates numbered {numbers of stock certificates}.

WHEREAS, I agree to release and hold harmless {corporation name} from any
claims of ownership or other legal actions that occur as a result of this loss.

WHEREAS, I will return the lost stock certificates should I locate them at any
point in the future.

THEREFORE, I am requesting that {corporation name} reissue {number} stock

certificates in my name.

Printed Name Signature

Date:

Notary Seal: