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Affidavit of Lost Certificate(s)
Claim # ____________
STATE OF_____________
COUNTY OF___________
I,__________________________, being duly sworn upon oath state that I am the rightful
claimant / owner of the following:
The original stock certificate(s) has/have been mislaid, destroyed, lost, or was/were held in a
brokerage account.
I have not sold, assigned or transferred in any manner whatsoever, the said certificate(s), stock,
or any interest therein. I am now the missing owner or rightful claimant of the stock and I make
and present this affidavit in proof of said lost stock and request the Office of the Nevada State
Treasurer transfer to me the deposit made by the issuer.
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__
BY: (Affiant)________________________
Notary Signature__________________ Notary Stamp
My Commission Expires____________
