Affidavit of Lost Certificate Representing Ownership Interest
I, [name of affiant], being first duly sworn under oath, depose and say:
1.My current address is [address].
2.I am the legal and beneficial owner of the following ownership interest in [name of corporation]:
|
Certificate No. |
Class |
Number of Interests |
Date of Issue |
Registered in the Name of: |
|
[certificate no.] |
[class] |
[number] |
[date] |
[name] |
|
Repeat as necessary. |
3.None of the above certificates, nor any of the rights of the owner therein, have in whole or in part been assigned, transferred, hypothecated, gifted, or otherwise disposed of.
4.I am entitled to the full and exclusive possession of the above certificates.
5.The circumstances giving rise to the loss, destruction, or theft of the certificates are as follows: [describe circumstances.]
6.The following efforts were made to locate the certificates: [describe efforts.]
7.I am making this Affidavit to request [name of corporation] to issue new certificates in lieu of those described above that have been lost, destroyed, or stolen. If new certificates are issued, I agree to surrender immediately to [name of corporation] any of the replaced certificates if I find them or if they are returned to me.
8.As an inducement for [name of corporation] to issue duplicate replacement certificates, I agree to fully indemnify and hold harmless [name of corporation] for any claim of ownership by any asserted owner or holder of the shares.
Dated: [date], in [city], [county] County, Texas.
[Name of affiant]
Notary Public, State of Texas
My commission expires:
____________________________, 20____