Affidavit of Lost Stock Certificate

AFFIDAVIT OF LOST STOCK CERTIFICATE

Before you use this: Confirm that the shares were certificated and ask the issuer or transfer agent for its replacement instructions. Identify every missing certificate separately. Do not sign until the oath or affirmation is administered.

State of [STATE]

County of [COUNTY]

I, [AFFIANT FULL NAME], being duly sworn or affirmed, state:

1. I am ☐ the registered owner ☐ the owner's authorized representative of the shares described below. My address is [ADDRESS]. If acting for another, my authority is [DESCRIBE AND ATTACH EVIDENCE].
2. Issuer: [LEGAL NAME]. Class or series: [CLASS]. Certificate number: [NUMBER OR UNKNOWN]. Number of shares: [NUMBER]. Date issued: [DATE OR UNKNOWN]. Name printed on certificate: [NAME]. Registration or account identifier: [IDENTIFIER].
3. I became the owner or representative of the owner on [DATE] through [DESCRIBE TRANSACTION OR AUTHORITY]. Supporting records are attached as Exhibit [LETTER].
4. The original certificate was last known to be at [PLACE] in the custody of [PERSON] on [DATE]. I discovered it was ☐ lost ☐ destroyed ☐ wrongfully taken on [DATE]. The circumstances are [FACTS; STATE ANY UNCERTAINTY].
5. I searched for the certificate by [DESCRIBE LOCATIONS, PERSONS, DATES, AND RESULTS]. I reported the loss or taking to [ISSUER / TRANSFER AGENT] on [DATE] by [METHOD]; confirmation is attached as Exhibit [LETTER OR NONE].
6. To my knowledge, I have not sold, assigned, pledged, delivered, or otherwise transferred the original certificate to another person. Any exception or competing claim is [DESCRIBE OR WRITE NONE].
7. I request that [ISSUER] review this affidavit and issue [A REPLACEMENT CERTIFICATE / UNCERTIFICATED SHARES, IF AVAILABLE] for the described shares under its applicable process. I will supply any separate bond, indemnity, or other documents lawfully required by the issuer. If the original is found, I will notify the issuer promptly and follow its instructions for surrender.

I have read this affidavit. The statements above are true to my personal knowledge except where I expressly identify records or another source.

Affiant signature: ______________________________ Date: [DATE]

Printed name and title: [NAME AND TITLE]

Exhibits: [LIST EACH ATTACHMENT OR WRITE NONE]

Oath or affirmation

Sworn to or affirmed and subscribed before me by [AFFIANT NAME] on [DATE] at [PLACE].

Notarial officer signature: ______________________________

Printed name and title: [NAME AND TITLE]

Commission, seal, and other details required where the oath is administered: [COMPLETE OR ATTACH LOCAL JURAT]