Lost Stock Certificate Affidavit

State of _______________

County of _______________

___________________, being duly sworn, hereby states under oath that they are an adult residing at _____________________.

1. The stock certificate(s) described below has been lost, stolen, or destroyed:
   • Description of Shares: ____________________________
   • Exact Name of Registered Owner (as it appears on the certificate): ____________________________
   • Name of Issuing Company: ____________________________
   • Number of Shares: ____________________________
2. The aforementioned stock is solely and exclusively owned by ____________________________.
3. The undersigned Affiant has diligently searched for the said certificate(s) but has been unable to locate or recover them. These securities, or any interest in them, have not been sold, assigned, endorsed, pledged, pawned, loaned, or otherwise transferred or disposed of in any way by the owner or by anyone on the owner’s behalf. No power of attorney, stock power, assignment, or authorization related to the said securities has been executed or remains valid. No individual, firm, or corporation has any claim, right, title, equity, or interest in or to said securities, except for the sole owner named above.
4. This affidavit is made to request and induce the issuer to issue a new or duplicate stock certificate to replace the lost, stolen, or destroyed one, without requiring the surrender of the original certificate or any payment, delivery, exchange, or credit associated with it, and/or to support the issuance of an indemnity bond.
5. Should a new or duplicate certificate be issued, or any transaction be processed in respect of the lost certificate, the Affiant agrees to return the original certificate to the issuer or, upon request, to its Transfer Agent for cancellation if it is later found or comes into the Affiant’s possession.

_____________________
Signature of Owner of Stock

Acknowledgment: Subscribed and sworn before me this ___ day of ____________, 20____.

__________________
Notary Public

My commission expires: ___________________

How to Use This Sample Format

This section is provided to help you understand and properly use the affidavit form above. If you lose a stock certificate, your first step should be to immediately notify the issuing company. Contact their Investor Relations department—typically via their official website—for guidance on the replacement process.

Filling out this affidavit helps you organize all necessary details clearly. Even if the company requires you to use their specific forms later, pre