Fillable Printable Affidavit of Loss - Utah

Affidavit of Loss - Utah

EXHIBIT B

AFFIDAVIT OF LOSS

STATE OF UTAH

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, namely:

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 wheth er signature was guaranteed.)

(4) Deponent has made or caused to be made diligent search for 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

(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 Agreement of Indemnity,

Exhibit “C”.)

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

and its agent to issue new securities in substitution for the Original and Seaboard Surety

Company to assume liability in respect thereof under its Indemnity Bond.

(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 Issuing Corporation,

its transfer agents, subscription agents, trustees or Seaboard Surety Company for cancellation.

(8) Signed, sealed and dated this __________ day of ___________________________, 1998.

Sworn to and subscribed before me

this _______ day of __________________

1998

____________________________________

Signature of Deponent

___________________________________

NOTARY PUBLIC (affix Notarial Seal)

My Commission expires: