Lost Stock Certificate Affidavit

STATUTORY DECLARATION OF LOST STOCK CERTIFICATE

IN THE MATTER OF the issuance of replacement share certificate(s) of ______ (the "Company"). The Company’s address is ______, ______.

I, ______, of the City of ______, in the Province/State of ______, DO SOLEMNLY DECLARE THAT: My address is ______.

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, encumber, or pledge any of the shares represented by the Certificates.

4. I release ______ 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 ______ 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.”

AND I make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under oath and by virtue of the Canada Evidence Act.

Signed and sworn (or affirmed/declared) before me by videoconference in Ottawa, Ontario, while the Affiant(s)/Declarant(s) were located in ______________________, on ______________________, pursuant to O. Reg. 431/20, and Electronic Commerce Act, 2000.