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AFFIDAVIT
AS TO LOST STOCK CERTIFICATE
STATE OF:
COUNTY OF:
I, ______________, BEING DULY SWORN DEPOSES AND SAYS THAT I/WE ARE THE
DEPONENT AND RESIDE AT: ______________________________________________________________________________
(STREET NUMBER) (CITY) (STATE & ZIP)
THAT DEPONENT IS OR ARE THE BENEFICIAL HOLDERS OF ___________
SHARES OF THE CAPITAL STOCK OF ______________
DESCRIBED AS FOLLOWS: