Affidavit Of Lost Stock Certificate

I,  ___________________________   of the__________________________, on this______ day of___________________ 201(x).



1. That the undersigned is the owner of record of______ shares of the common

stock of___________________________, (the "Corporation") as same appear on the books and records of the Corporation as certificate number______________.

2. The undersigned has made a due and diligent search for the said stock certificate but has lost or misplaced same.  The undersigned warrants and represents that the said stock certificate has not been sold, pledged or transferred.

3. As an inducement for the Corporation issuing a duplicate replacement certificate, the undersigned agrees to fully indemnify and save harmless the Corporation for any claim of ownership by any asserted owner or holder of the said shares.






STATE OF _____________________   COUNTY OF ______________________  


In _______________, on the _____________ day of ____________, 201(x),
before me, a Notary Public in and for the above state and county, personally
appeared (NAME OF AFFIANT),  known to me or proved to be the person
named in and who executed the foregoing instrument, and being first duly
sworn, such person acknowledged that he or she executed said instrument for
the purposes therein contained as his or her free and voluntary act and deed.  

Type of Identification Produced: _________________________   

Affiant is / is not personally known to me (          )  


My Commission Expires: ________________



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