Affidavit for Lost, Stolen, or Destroyed Stock Certificate

Affidavit for Lost, Stolen, or Destroyed Stock Certificate STATE OF ____________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, ______________________ (Name of Affiant), who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. That I reside at __________________________________________________________ _________________________________________ (street address, city, state, zip code). 2. That I am the legal and beneficial owner of __________ (number) shares of the (specify class) _________________________ stock of ________________________ (name of corporation) represented by certificates described as follows: Number: _________ Date: ________________ Registered Name: ______________ (state number) (state date) _____________________________ (state registered name) Affidavit for Lost, Stolen, or Destroyed Stock Certificate STATE OF ____________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, ______________________ (Name of Affiant), who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. That I reside at __________________________________________________________ _________________________________________ (street address, city, state, zip code). 2. That I am the legal and beneficial owner of __________ (number) shares of the (specify class) _________________________ stock of ________________________ (name of corporation) represented by certificates described as follows: Number: _________ Date: ________________ Registered Name: ______________ (state number) (state date) _____________________________ (state registered name) Affidavit for Lost, Stolen, or Destroyed Stock Certificate STATE OF ____________________ COUNTY OF _______________________ PERSONALLY appeared before me, the undersigned authority in and for said county and state, ______________________ (Name of Affiant), who, having been being first duty sworn by the undersigned Notary Public, deposes and says: 1. That I reside at __________________________________________________________ _________________________________________ (street address, city, state, zip code). 2. That I am the legal and beneficial owner of __________ (number) shares of the (specify class) _________________________ stock of ________________________ (name of corporation) represented by certificates described as follows: Number: _________ Date: ________________ Registered Name: ______________ (state number) (state date) _____________________________ (state registered name)