Lost Stock Certificate Affidavit Template
State of [State]
County of [County]
Before me, the undersigned authority, personally appeared [Affiant Full Name], who, being duly sworn, states as follows:
Affiant Name: [Full Name]
Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]
The Affiant is:
☐ the registered owner of the stock certificate
☐ an authorized representative of the owner
☐ other: [Describe]
Corporation Name: [Company Name]
State of Incorporation, if known: [State]
The stock certificate that is the subject of this affidavit is described as follows:
Certificate Number: [Certificate Number, if known]
Number of Shares: [Number]
Class or Series of Stock: [Common / Preferred / Other]
Name Registered on Certificate: [Full Name]
If the certificate number is unknown, additional identifying details are:
[Insert details]
4. Statement of Ownership
The Affiant states that the Affiant is the lawful owner of the shares represented by the certificate described above or is otherwise authorized to make this affidavit concerning those shares.
The Affiant further states that the shares have not been sold, assigned, pledged, endorsed, transferred, or otherwise disposed of except as stated below:
[Insert details or write “None”]
5. Statement of Loss
The certificate described above has been:
☐ lost
☐ stolen
☐ destroyed
☐ misplaced
☐ other: [Describe]
Date discovered missing: [Date]
Location or last known location of certificate, if known:
6. Circumstances of Loss
The facts surrounding the loss, theft, destruction, or misplacement of the certificate are as follows:
[Describe the circumstances in detail]
Efforts made to locate the certificate:
[Describe search efforts]
7. No Possession by Affiant
The Affiant does not currently have possession, custody, or control of the original certificate.
To the best of the Affiant’s knowledge, the certificate has not been endorsed, negotiated, transferred, or delivered to any unauthorized person.
8. Request for Replacement
The Affiant requests that the corporation, transfer agent, or other authorized party issue a replacement certificate or replacement record for the shares described above, subject to any additional requirements, fees, bond, indemnity, or transfer procedures that may apply.
9. Indemnity Acknowledgment
The Affiant understands that the corporation or transfer agent may require additional documentation or protection before issuing a replacement, including an indemnity bond or similar protection, as commonly required in lost certificate replacements.
Additional acknowledgment, if any:
10. Notice of Original Certificate
If the original certificate is later found, the Affiant agrees to:
promptly notify the corporation or transfer agent;
not transfer, negotiate, or use the original certificate;
return the original certificate if required.
The following supporting materials are attached or available, if needed:
☐ copy of identification
☐ account statement or ownership record
☐ correspondence with transfer agent
☐ police report, if theft is involved
☐ other: [Describe]
12. Certification
The Affiant certifies that the statements in this Lost Stock Certificate Affidavit are true and correct to the best of the Affiant’s knowledge and belief.
The Affiant understands that this affidavit may be relied upon for purposes of replacement, transfer control, and related stock record actions.
13. Signature
Affiant Signature: __________________________
Name: [Full Name]
Date: [Date]
14. Notary Acknowledgment
Subscribed and sworn to before me on this [Day] of [Month], [Year], by [Affiant Full Name].
Notary Public Signature: __________________________
Name: [Notary Name]
My Commission Expires: [Date]
15. Optional Transfer Agent Section
Transfer Agent Name: [Name]
Reference Number: [Number]
Replacement Request Date: [Date]
Additional Requirements Noted: [Bond / Fee / Medallion / Other]
