Affidavit of Loss - Bay City Transfer

(Complete in triplicate)
AFFIDAVIT OF LOSS
We/I, (hereinafter called “deponent”) of legal
age, being duly sworn, deposes and says:
1. Deponent resides at: , City/Town Province/State
Postal/Zip Code and is by occupation
2. THAT I am authorized to make this my Affidavit on behalf of and
has personal knowledge of the facts hereinafter deposed to, except where such facts are stated to be on information on belief and where
so stated, I verily believe such facts to be true. (Complete #2 if deponent is a corporation)
3. Description of Lost Share Certificate(s) [ ] Bond(s) [ ] (hereinafter called the “Certificate”):
Certificate No. Number of Shares Shares of / Stock Issue Registered in the Name of
4.
The said Certificate has been lost, stolen, destroyed or misplaced in the manner following, to wit:
Where kept
How lost
When missed (date of Loss)
If stolen, provide details and copy of police report
5. Was said Certificate(s) endorsed? YES [ ] NO [ ]
If answer to above was YES; was signature also guaranteed? YES [ ] NO [ ],
Also, describe form of endorsement
6. Deponent has caused a search for the Certificate and has not been able to find or recover same, and that Deponent was the
unconditional owner of the Certificate at the time of loss and is entitled to the full and exclusive possession thereof; that neither the
Certificate nor the rights of the Deponent therein have, in whole or in part, been assigned, transferred, hypothecated, pledged or
otherwise disposed of, in any manner whatsoever, and that no person, firm or corporation other than Deponent has any right, title claim,
equity or interest in, to, or respecting Certificate or the proceeds thereof, except as may be set forth in the following statement:
If Deponent’s interest in the Certificate is in a representative or fiduciary capacity, indicate below the designation of such capacity
(example, Administrator, Executor, Guardian, Power of Attorney etc.). Provide supporting documentation of representative capacity:
Deponent is of the Estate of
(Specify names of any persons having an interest in the Certificate. List them below and indicate the nature of their interest, such as
heir legatee, etc. - If space below is not sufficient please provide attachment.)
NAME & ADDRESS PERCENTAGE OF INTEREST
__________________________________________________ _ _ _________________________
__________________________________________________ _________________________
_________________________________________________ _ ____ _________________________
7.
Deponent agrees that if said Certificate should ever come into Deponent’s hands, custody or power, Deponent will immediately and
without consideration surrender Certificate to the Issuing Corporation, its transfer agents, subscription agents, or trustees for
cancellation.
Signed, sealed and delivered by deponent, this day of , .
SIGNATURE OF DEPONENT - PRINT NAME / ADDRESS / TITLE (if applicable):
A COMMISSIONER, NOTARY PUBLIC IN AND FOR THE PROVINCE / STATE OF
On this day of ______________ __, _______, before me personally appeared to
me known and known to me to be the individual(s) described in and who executed the foregoing instrument, and they duly acknowledged to me that they executed the same for
the purpose above stated, and being by me duly sworn, did depose and say that the statements therein contained are true.
(Affix Notarial Seal)
Notary Public My Commission Expires
SIGNATURE OF DEPONENT - PRINT NAME / ADDRESS / TITLE (if applicable):
A COMMISSIONER, NOTARY PUBLIC IN AND FOR THE PROVINCE / STATE OF
On this day of ______________ __, _______, before me personally appeared to
me known and known to me to be the individual(s) described in and who executed the foregoing instrument, and they duly acknowledged to me that they executed the same for
the purpose above stated, and being by me duly sworn, did depose and say that the statements therein contained are true.
(Affix Notarial Seal)
Notary Public My Commission Expires
SIGNATURE OF DEPONENT - PRINT NAME / ADDRESS / TITLE (if applicable):
A COMMISSIONER, NOTARY PUBLIC IN AND FOR THE PROVINCE / STATE OF
On this day of ______________ __, _______, before me personally appeared to
me known and known to me to be the individual(s) described in and who executed the foregoing instrument, and they duly acknowledged to me that they executed the same for
the purpose above stated, and being by me duly sworn, did depose and say that the statements therein contained are true.
(Affix Notarial Seal)
Notary Public My Commission Expires
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