Affidavit for Lost, Stolen, Destroyed Stock Certificate

Topics: Notary public, Witness, Acknowledgment Pages: 12 (1971 words) Published: March 5, 2011

State/Province of ______________________
County of _____________________

I, [name] , being duly sworn, state:

That I reside at [address], [city] , [state]

That I am the legal and beneficial owner of [number]
shares of the [specify class] stock of [corporation]
represented by certificates described as follows:

Number Date Registered Name

That said certificates [were or were not] endorsed.

That I have not assigned, hypothecated, pledged, or in any
other way disposed of either the stock certificates or my
rights as a stockholder, in whole or in part.

That I am entitled to full and exclusive possession of said

That the circumstances surrounding the [loss, or theft,
or destruction, or disappearance] of said certificates
and my attempt to locate them are as follows:

That the purpose of preparing this affidavit is to induce
[corporation] to issue new certificates to replace those
that have been [lost, stolen, destroyed].

I hereby agree to surrender to [corporation] the
original certificates issued to me should they hereafter
come into my possession or control.



LAST WILL AND TESTAMENT OF [list name of testator]

I, [list name of testator], residing at [city, prov/state of testator], being of sound mind, do hereby declare this instrument to be my last will and testament.

I hereby revoke all previous wills and codicils.

I direct that the disposition of my remains be as follows:

[list burial instructions]


I give all the rest and residue of my estate to my spouse, [list spouse's full name], should [she, he] survive me for 60 days. If my spouse, [list spouse's full name], does not survive me, I give all the rest and residue of my estate to [list alternate beneficiary's name]. If neither [list spouse's full name] nor [list alternate beneficiary's name], survives me, I give all the rest and residue of my estate to my heirs as determined by the laws of the prov/State of prov/state where executed], relating to descent and distribution.

I appoint [list name of executor], to act as the executor of this will, to serve without bond. Should [list name of executor] be unable or unwilling to serve, then I appoint [list name of alternate executor] to act as the executor of this will.

I herewith affix my signature to this will on this

the ____________ day of ________________________________, 20___

at ________________________________________, in the presence of the following witnesses, who witnessed and subscribed this will at my request, and in my presence.


On the date above written, [list name of testator], a person known to us, appeared to us to be of sound mind and lawful age, and under no undue influence. Further [list name of testator], declared to us, and in our presence, that this instrument, consisting of _____ pages, is their last will and testament, and [list name of testator], then signed this instrument in our presence, and at [list name of testator]'s request we now sign this will as witnesses in each other's presence.




Address: ______________________________________________________




Address: ______________________________________________________




Address: ______________________________________________________

Province/State of [prov/state where executed]
COUNTY OF [country executed]
Before me, the undersigned authority authorized to take acknowledgments and administer oaths, personally appeared:

[list name of testator]...
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