Lost Stock Certificate Affidavit

AFFIDAVIT OF LOST STOCK CERTIFICATE

IN THE MATTER OF the issuance of replacement share certificate(s) of ______ (the "Company").

I, ______, of the City of ______, in the Province/State of ______, DO SOLEMNLY DECLARE THAT:

1. I am the owner of a total of ______ shares of the Common Stock of ______, Inc., a ______ corporation (the “Company”).

2. I have examined my records and, after diligent search, I am unable to find the certificate or certificates representing such shares (the “Certificates”) and I believe that the Certificates were lost.

3. I did not transfer, sell, encumbered, or pledged any of the shares represented by the Certificates.

4. I release the ______ and any successor from any and all liability relating to the loss of the Certificates, or the issuance of new Certificates.

5. I agree to defend and indemnify and hold harmless the ______ and any successor from any damage or loss caused by the loss of the Certificates.

6. In the event of discovery of the original Certificates, the undersigned agrees to return them promptly to the Company or any successor, marked “CANCELLED.”

Additional information

Company Province: ______

Company Address: ______

Stockholder Address: ______