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Affidavit for lost or Stolen Share Certificate Template

We’ve prepared a bundle of letter templates to be used in general business situation. Feel free to use them with our compliments. However we ask that you do not reproduce these templates on any medium for public display or re-sale.

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State of ______________________

Shire of _____________________

I, [name], being duly sworn, state:

That I reside at [address], [city], [state] That I am the
legal and beneficial owner of [number] shares of the
[specify class] stock of [corporation] represented by
certificates described as follows:

Number Date Registered Name

That said certificates [were or were not] endorsed.

That I have not assigned, hypothecated, pledged, or in any
other way disposed of either the stock certificates or my
rights as a stockholder, in whole or in part.

That I am entitled to full and exclusive possession of said

That the circumstances surrounding the [loss, or theft, or
destruction, or disappearance] of said certificates and my
attempt to locate them are as follows:

That the purpose of preparing this affidavit is to induce
[corporation] to issue new certificates to replace those
that have been [lost, stolen, destroyed].

I hereby agree to surrender to [corporation] the original
certificates issued to me should they hereafter come into my
possession or control.



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