Affidavit Of Lost Stock Certificate And Indemnity Agreement {AFF-205}

Affidavit of Lost Stock Certificate and Indemnity Agreement STATE OF ) COUNTY OF ] TO THE (insert Name): I, , do hereby swear and affirm that the stock certificate(s) & indemnity agreements issued to by has been misplaced or destroyed and that the stock certificate(s) & indemnity agreements has not been sold, pledged, hypothecated or otherwise transferred. If any time in the future the stock certificate is located, I shall surrender it immediately to the concerned authority, and I shall not make further claim on the stock certificate. The undersigned agrees to indemnify and hold harmless the issuer, its officers and employees from any loss resulting from the payment of this claim. In witness whereof, the parties have caused this agreement to be executed the day and year first above written. Name: Print Name: Address: Name: Print Name: Address: I, the undersigned, a Notary Public in and for said County, in aforesaid state, do hereby certify that . Personally known to me to be the same person whose name is subscribed to the foregoing instrument, appeared before me this day in person, and acknowledged that signed, scaled and delivered the said instrument, as his/ her/their free and voluntary act, for the uses and purposes therein set forth. Given under my hand and notarial seal, this day of , 20 . Signature of the Notary public (seal) Print Name of the Notary public American LegalNet, Inc. © www.FormsWorkFlow.com