Affidavit of Loss Form - Empire Stock Transfer

AFFIDAVIT OF LOSS
The undersigned (“Deponent”), being duly sworn, deposes and affirms as follows:
1. Deponent is an adult who resides at:
Address
And is the legal and beneficial owner or is acting in a representative or fiduciary capacity with respect to
the following securities (the “Securities”):
Issuer name
Certificate Number(s)
Number of Shares
2. Deponent does further affirm that the Securities have been:
Lost Stolen Destroyed
3. That the Securities were not endorsed.
4. That the Securities have not, in whole or part, been assigned, transferred, hypothecated, pledged
or otherwise disposed of in any manner whatsoever, and that no person or entity other than the
Deponent has any right, title, claim or interest in the same.
5. Deponent agrees that if the Securities should ever come into Deponent’s hands, by power or
custody, Deponent will immediately and without consideration surrender the Securities to Empire
Stock Transfer Inc. for cancellation.
Signed Printed Name(s) Dated
Sworn to before me this day:
Date
Notary Public Expiration of Commission
NOTARY SEAL
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Affidavit of Loss Form - Empire Stock Transfer PDF

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