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Affidavit of Lost Stock Certificate

Complete this form to report a lost stock certificate and acknowledge that the shares of stock has not been sold, transferred or pledged.

Click here for a sample. All information appearing in bold type are the form fields that are either automatically completed by the program or completed based on information you supplied in this form.

Affiant's Name:
(your name)
Gender:
Address:
(your street address)
City:
State or Province:
(Select a state or Canadian province)
Zip/Postal Code:
Country:
Number of Shares:
(Enter how many shares of stock you own)
Corporation:
(Enter the name of the corporation of which you own stock)
Certificate Number:
(Enter the certificate number of the lost stock certificate)
Signed on://
(Select the month, day and year on which you'll sign this affidavit)

This is not a substitute for legal advice and it is suggested that an attorney be consulted.

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