Affidavit for Stolen Stock Certificate



Affidavit for Stolen Stock Certificate :




This letter should be typed in the official letter-head of the company.

The Company's Name

Door Number and Street's Name,
Area Name,
City.
Postal Code : XXXXXX
Phone Number : 0000 - 123456789


TO :

The Receiver's Name,
Door Number and Street's Name,
Area Name,
City.
Postal Code : XXXXXXX


Date :


Reference :


Dear _____________,


State of :


County 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 certificates.


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 stolen.


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


Dated :


[Signature] :


[Jurat]


Yours Sincerely,


(The Sender's Signature)


The Sender's Name


Enc. :







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Affidavit for Stolen Stock Certificate
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