AFFIDAVIT FOR LOST, STOLEN, DESTROYED STOCK CERTIFICATE

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:

Number Date Registered Name

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.

Dated:_____________________

____________________

[Signature]

[Jurat]