State of [State]

County of [County]

Introduction:

I, [Your Name], being duly sworn, depose and state:

Statement of Facts:

1. I, [Your Name], residing at [Your Address], and reachable via [Your Number] and [Your Email Address], hereby make this affidavit in my capacity as [Your Relationship, e.g., Investor, Shareholder].

2. I attest under oath and affirm the truthfulness of the statements and commitments made herein, acknowledging my relationship to the issuer and the responsibilities entailed.

3. I hereby declare that the following securities or financial documents have been lost, stolen, or destroyed and have not been endorsed, sold, assigned, or transferred to any other party nor encumbered in any way.

4. The type of security involved is [Type, e.g., Stock Certificate, Bond], issued by [Issuer's Name]. The certificate number(s) in question is/are [Certificate Number(s)], representing [Number of Shares or Face Value].

5. This declaration is made in good faith, with the understanding that these securities are no longer in my possession nor under my control in any capacity.

Indemnity Agreement:

I agree to indemnify and hold harmless [Issuer's Name] and their agents, successors, and assigns from any claim, loss, liability, or expense that arises as a result of the issuance of a duplicate security or from any claim or demand related to the lost, stolen, or destroyed security.

Affirmation of Truth:

I affirm that the information provided in this affidavit is true and accurate to the best of my knowledge and belief. I understand that if any of the above statements are made knowingly false, I may be subject to penalties under the law.

Further Action:

I agree to surrender the original security to [Issuer's Name] immediately if it is found or recovered and to notify [Issuer's Name] of any information regarding the recovery of the lost security.

Signature:

[Your Name]

Subscribed and sworn to before me this ___ day of [Month], [Year].

[Notary Public]

Executed this [day] of [Month], [Year].

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