State of ____________.
County of ___________.
I, [name], being duly sworn, state:
That I reside at [address], [city], [state] That I am the legal and beneficial owner of [number] shares of the [specify class] stock of [corporation] represented by certificates described as follows:
That said certificates [were or 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.
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