Affidavit of Lost, Stolen or Destroyed Stock Certificate

Company Letterhead

{{company_name}}

{{company_address}}

Phone: {{phone}}

Email: {{email}}

Website: {{website}}

AFFIDAVIT OF LOST, STOLEN OR DESTROYED STOCK CERTIFICATE

I, {{affiant_name}}, of lawful age, residing at {{affiant_address}}, {{affiant_city}}, {{affiant_province_state}}, {{affiant_country}}, do hereby depose and state under oath as follows:

DECLARATION OF OWNERSHIP

1. I am the registered owner of {{number_of_shares}} ({{number_of_shares_words}}) ordinary shares of {{company_name}} (the “Company”), represented by Share Certificate Number {{certificate_number}}, dated {{certificate_date}} (the “Original Certificate”).

CIRCUMSTANCES OF LOSS/THEFT/DESTRUCTION

2. The Original Certificate has been {{loss_type}} on or about {{loss_date}} at {{loss_location}} under the following circumstances: {{circumstances_of_loss}}.

DILIGENT SEARCH

3. I have made diligent search for the Original Certificate and have been unable to find or recover it. The Original Certificate has not been assigned, transferred, endorsed, hypothecated, pledged, or otherwise disposed of, and I am the sole owner thereof.

INDEMNITY

4. I hereby undertake to indemnify and hold harmless the Company, its directors, officers, employees, and agents, from and against any and all claims, actions, liabilities, demands, losses, costs, expenses, and damages (including legal fees) which may arise from or in connection with the issuance of a replacement certificate, or from any person claiming to be a holder of the Original Certificate.

REQUEST FOR REPLACEMENT

5. I hereby request the Company to issue a new stock certificate in replacement of the Original Certificate. I understand that the Company may require a bond or other security as a condition for issuing such replacement certificate.

GOVERNING LAW

6. This Affidavit shall be governed by and construed in accordance with the laws of {{country_of_incorporation}}.

SWORN STATEMENT

IN WITNESS WHEREOF, I have hereunto set my hand this {{day}} day of {{month}}, {{year}}.

Signature Block

Deponent: __________________________

{{affiant_name}}

SUBSCRIBED AND SWORN to before me this {{day}} day of {{month}}, {{year}}, by {{affiant_name}}, who is personally known to me or identified through satisfactory evidence.

__________________________

Notary Public

My Commission Expires: {{notary_commission_expiry_date}}