Claim #: __________
AFFIDAVIT OF LOST INSTRUMENT
STATE OF ______________ )
1. That the Affiant(s) is /are of legal age and reside(s) at ______________________ and that
he/she/they is/are the lawful owner(s) of and entitled to possession of the Lost Instrument(s) described as
2. Affiant(s) state(s) that said Lost Instrument(s) was/were apparently mailed to an improper
address or otherwise lost and cannot now be produced.
3. Said Lost Instrument(s) was/were not endorsed. Neither said Lost Instrument(s) nor the rights
of the Affiant(s) in said Lost Instrument(s) have been cashed, negotiated, assigned, transferred, deposited
under my agreement or otherwise disposed of, and to the knowledge of the Affiant(s), no claim of right,
adverse Affiant(s) in said Lost Instrument(s) has been made by any person.
4. Affiant(s) has/have made diligent search for said Lost Instrument(s) and has been unable to
the same and makes this Affidavit of Lost Instrument(s) for the purpose of obtaining the distribution from
______________________ Affiant(s) hereby agree(s) to surrender said Lost Instrument(s) for
cancellation should such Lost Instrument(s) at any time hereafter come into the hands, custody or power
of the Affiant(s).
5. I further agree with the Office of the Nevada State Treasurer that if any court of competent
jurisdiction rules that any person has a superior demand to said money or and/or shares, I will return all
items to the State Treasurer obtained based on this affidavit. I also agree to indemnify the State Treasurer
for any damages, costs, and attorneys fees incurred by reason of such ruling.
I acknowledge that I understand that filing a false affidavit constitutes a felony in this state. I declare
under penalty of perjury under the laws of the State of Nevada that the foregoing is true and correct.
Signed and sworn before me this ____ day of ________________, 20__
Notary Signature__________________ Notary Stamp
My Commission Expires____________