Affidavit of Loss - Kansas

AFFIDAVIT OF LOSS
STATE OF
COUNTY OF
The undersigned (hereinafter called “Deponent”), being duly sworn, deposes and says that:
(1) Deponent is an adult whose mailing address is
and is the owner of or is acting in a representative or fiduciary capacity with respect to certain securities
(describe type of security, identification number, and number of shares or face value):
issued by
(hereinafter called the “Issuing Corporation”) and registered in the name of:
(2) Deponent further says that the aforesaid security or securities (hereinafter called the “Original”,
whether one or more) have been lost, stolen, destroyed or misplaced under the following
circumstances:
(3) That said Original ( was / was not ) endorsed. (If endorsed, describe form of endorsement and
state whether signature was guaranteed.)
(4) Deponent has made or caused to be made diligent search of Original, and has been unable to find
or recover same, and that Deponent was the unconditional owner of Original at the time of loss,
and is entitled to the full and exclusive possession thereof; that neither the Original nor the rights
of 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 Original or
the proceeds thereof, except as may be set forth in Statement (5) following.
(5) If Deponent’s interest in the Original is in a representative or fiduciary capacity, indicate below
the designation of such capacity, i.e., Administrator, Executor, etc. And the title of the estate, as
follows:
Deponent is of the estate of
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