AFFIDAVIT OF LOST STOCK CERTIFICATE STATE OF: __________) ) SS COUNTY OF :________) _________________, [Insert Name] (the Holder), of __________________________

[Insert Address] being duly sworn, does hereby swear and affirm as follows: 1) The Holder is of legal age and is the sole legal and beneficial owner of _______________ [Number] shares of _____ [class] stock, ________ par value, of ______________, a ______ [corporation][limited liability company][etc.] (the Company), represented by Certificate Number[s] _________________________ (the Original Certificate[s]), issued on __________ [date] by the Company in the name of the Holder. 2) The Original Certificate[s] has/have been [lost] [stolen] [destroyed]. 3) The Original Certificate[s] was/were [not endorsed] [endorsed as follows: ________________________________________________________________ _________________________________________________________________ ______________________________________________________________. 4) None of the Original Certificate[s], or any of the Holders rights therein, have, in whole or in part, been assigned, transferred, hypothecated, pledged, gifted, or otherwise disposed of in any manner whatsoever. 5) The Holder is entitled to the full and exclusive possession of the Original Certificate[s], and no other person or entity has any right, title, claim, equity, or interest in, to, or respecting the Original Certificate[s] or the proceeds thereof. 6) The Holder has made the following efforts to locate the Original Certificate[s] [The destruction of the Original Certificate[s] occurred as follows]: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ____. 7) If the Holder ever locates the Original Certificate[s], or if they are otherwise returned to the Holder, the Holder agrees that such Original Certificate[s] has/have no value and that it will surrender those recovered Original Certificate[s] to the Company immediately and without consideration for cancellation.

Affidavit of Lost Stock Certificate

8) The Holder hereby requests and is making this affidavit (the Affidavit) for the purpose of requesting the Company to issue new or duplicate stock certificates in substitution for the Original Certificate[s]. IN WITNESS WHEREOF, the Holder has executed this Affidavit on the date set forth below. Date: __________________ ________________________________ Signature of _______________ [Holder Name]

State of ____________) )SS County of __________) On this ____ day of ____________, 20___, before me, _____________________________, personally appeared _________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he or she executed the same for the purposes above stated, and, being by me duly sworn, did depose and state that the statements therein contained are true. WITNESS my hand and official seal. ______________________________ Notary Public My Commission Expires: _____________

Affidavit of Lost Stock Certificate