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AFFIDAVIT OF LOST STOCK CERTIFICATE
State of Illinois
County of _____________
___________________, being first duly sworn on oath deposes and says that he/she is an adult and resides at _____________________.
1. The certificate(s) representing the following described shares of stock has been lost,
stolen or destroyed: ____________________________.
The Registered owner's exact name as it appears on the original certificate:
Number of shares:
2. The above-described stock is solely owned by ________________.
3. That Affiant has made or caused to be made a diligent search for said securities and
has been unable to find or recover same. Neither said securities nor any interest therein has been sold, assigned, endorsed, pawned, pledged for any bank or brokerage loan or otherwise, or disposed of in any manner by or on behalf of said owner. Neither said owner nor anyone on said owner's behalf has signed any power of attorney, any stock power, or other assignment or authorization respecting the same which is now outstanding and in force. No person, firm or corporation has any right, title, claim, equity, or interest in, to, or respecting said securities, excepting the sole owner above named.
4. That this affidavit is made for the purpose of inducing the issuance of a new or duplicate certificate in substitution of or in exchange for said lost, stolen or destroyed certificate without requiring the surrender of the original, or the payment, delivery, exchange, or credit in respect of such original without such surrender, and/or inducing to issue an indemnity bond.
5. If such new or duplicate certificate(s) is so issued, countersigned and registered, or such payment, delivery, exchange or credit is made in respect of such original(s), then it is understood and Affiant hereby agrees that if said lost certificate comes into Affiant's control or custody, the recovered stock certificate will be delivered to the issuer or, at issuer's request, to issuer's Transfer Agent, for the purpose of cancellation.
Owner of Stock
State of: Illinois