Fillable Printable Affidavit of Loss - Kansas

Affidavit of Loss - Kansas

AFFIDAVIT OF LOSS

STATE OF

COUNTY OF

The undersigned (hereinafter called “Deponent”), being duly sworn, deposes and says that:

(1) Deponent is an adult whose mailing address is

and is the owner of or is acting in a representative or fiduciary capacity with respect to certain securities

(describe type of security, identification number, and number of shares or face value):

issued by

(hereinafter called the “Issuing Corporation”) and registered in the name of:

(2) Deponent further says that the aforesaid security or securities (hereinafter called the “Original”,

whether one or more) have been lost, stolen, destroyed or misplaced under the following

circumstances:

(3) That said Original ( was / was not ) endorsed. (If endorsed, describe form of endorsement and

state whether signature was guaranteed.)

(4) Deponent has made or caused to be made diligent search of Original, and has been unable to find

or recover same, and that Deponent was the unconditional owner of Original at the time of loss,

and is entitled to the full and exclusive possession thereof; that neither the Original nor the rights

of Deponent therein have, in whole or in part, been assigned, transferred, hypothecated, pledged

or otherwise disposed of, in any manner whatsoever, and that no person, firm or corporation

other than Deponent has any right, title, claim, equity or interest in, to, or respecting Original or

the proceeds thereof, except as may be set forth in Statement (5) following.

(5) If Deponent’s interest in the Original is in a representative or fiduciary capacity, indicate below

the designation of such capacity, i.e., Administrator, Executor, etc. And the title of the estate, as

follows:

Deponent is of the estate of

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(Specify names of any other persons having an interest in the Original. List them below and

indicate the nature of their interest, such as heir, legatee, etc.)

Name Interest

(Each heir, legatee, etc. having an interest in the Original must execute the Agreement of

Indemnity.)

(6) Deponent makes this affidavit for the purpose of requesting the Issuing Corporation and its agents

to issue new securities in substitution for the Original.

(7) Deponent agrees that if said Original should ever come into Deponent’s hands, custody or power,

Deponent will immediately and without consideration surrender Original to the Issuing

Corporation or its transfer agent(s).

(8) Signed, sealed and dated __________________________________ 20______.

Sworn to and subscribed before me

this _______________ day of _______________ 20_____.

___________________________________

Signature of Deponent

___________________________________

Notary Public

(Affix Notarial Seal)

My Commission expires:

Sworn to and subscribed before me

this _______________ day of _______________ 20_____.

___________________________________

Signature of Deponent

___________________________________

Notary Public

(Affix Notarial Seal)

My Commission expires:

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