STATE OF ..................)
ss. ) [city]
COUNTY OF .................)
[Name of Transferor] (Deponent), being duly sworn, deposes and says, that Deponent is the true and lawful, present and sole owner of the certificate number [number] for [number] shares of Common Stock of [Name of Corporation], a corporation organized and existing under the laws of the State of [state] (Corporation) which deponent believes has been lost, mislaid, stolen or destroyed:
Deponent believes that said certificate of stock has been lost, mislaid, stolen or destroyed, because all efforts to locate it have been unsuccessful.
Deponent further states that the certificate was not endorsed, that it has not been hypothecated, sold, delivered, transferred or assigned and does hereby agree that in the event of the recovery of the certificate in lieu thereof, deponent will cause same to be returned to Corporation for cancellation.
This affidavit is being made to induce the Corporation as issuing corporation to issue a new or duplicate certificate to deponent in lieu of the aforementioned lost certificate of stock, and deponent agrees to indemnify said Corporation for any loss or expense to which it may be put as a result of said lost certificate.
Deponent further states that the above statements are true to deponent's knowledge, information and belief.
Subscribed and sworn to by [Name of Transferor] this [date] before me.
Name of Notary Public: [name]
My commission expires: [date]