Affidavit of Loss - Utah

EXHIBIT B
AFFIDAVIT OF LOSS
STATE OF UTAH
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, namely:
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 wheth er signature was guaranteed.)
(4) Deponent has made or caused to be made diligent search for 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
(Specify names of any other persons having an interest in the Original. List them below and
indicate the nature of their interest, such as heir, legatee, etc.)
NAME INTEREST
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