Fillable Printable Affidavit of Loss Form - Empire Stock Transfer

Affidavit of Loss Form - Empire Stock Transfer

AFFIDAVIT OF LOSS

The undersigned (“Deponent”), being duly sworn, deposes and affirms as follows:

1. Deponent is an adult who resides at:

Address

And is the legal and beneficial owner or is acting in a representative or fiduciary capacity with respect to

the following securities (the “Securities”):

Issuer name

Certificate Number(s)

Number of Shares

2. Deponent does further affirm that the Securities have been:

Lost Stolen Destroyed

3. That the Securities were not endorsed.

4. That the Securities have not, in whole or part, been assigned, transferred, hypothecated, pledged

or otherwise disposed of in any manner whatsoever, and that no person or entity other than the

Deponent has any right, title, claim or interest in the same.

5. Deponent agrees that if the Securities should ever come into Deponent’s hands, by power or

custody, Deponent will immediately and without consideration surrender the Securities to Empire

Stock Transfer Inc. for cancellation.

Signed Printed Name(s) Dated

Sworn to before me this day:

Date

Notary Public Expiration of Commission

NOTARY SEAL