AFFIDAVIT FOR LOSS
State of ______________________
County of _____________________
I,______ , being duly sworn, state residing at ______(address)____.I hereby state that I have ____(number)___ of shares in stock of _____(corporation)___.The proofs are added below.
The above said certificates are enclosed..That I am entitled to full and exclusive possession of said certificates.The reason which caused the loss of the above said certificates are the my attempt to find it back are as described below:
The purpose of this affidavit is to get the certificates back from the corporation.I hereby declare that ,I will surrender the original certificates if it is back.
This affidavit is prepared dated ______
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