AFFIDAVIT OF LOST STOCK CERTIFICATE
________________________________________________

This Affidavit of Lost Stock Certificate (the “Agreement”) is made and effective [DATE],

BETWEEN:                    [YOUR COMPANY NAME] (the "Company"), a corporation organized and existing under the laws of the [State/Province] of [STATE/PROVINCE], with its head office located at:

[YOUR COMPLETE ADDRESS]

AND:                              [STOCKHOLDER NAME] (the "Stockholder"), an individual/ a corporation organized and existing under the laws of the [State/Province] of [STATE/PROVINCE], with its head office located at:

[COMPLETE ADDRESS]

TERMS

The undersigned Stockholder hereby declares, under penalty of perjury, as follows:

1. The undersigned is the owner of a total of [number of shares] shares of the Common Stock of [name of company], Inc., a [state where company incorporated] corporation (the “Company”).
    
2. The undersigned has examined his, her or its records and, after diligent search, is unable to find the certificate or certificates representing such shares (the “Certificates”) and believes that the Certificates were lost.
    
3. The undersigned has not transferred, sold, encumbered, or pledged any of the shares represented by the Certificates.
    
4. The undersigned releases the Company and any successor from any and all liability relating to the loss of the Certificates, or the issuance of new Certificates. The undersigned agrees to defend and indemnify and hold harmless the Company and any successor from any damage or loss caused by the loss of the Certificates.
    
5. In the event of discovery of the original Certificates, the undersigned agrees to return them promptly to the Company or any successor, marked “CANCELLED.”

IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date first above written.

COMPANY                                                                   STOCKHOLDER

Authorized Signature                                                     Authorized Signature

________________________________                      _________________________________

Print Name and Title                                                     Print Name and Title