© Copyright Envision Corporation. 2002. All rights reserved.

Protected by the copyright laws of the United States & Canada and by international treaties. IT IS
ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER
PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

AFFIDAVIT OF LOST STOCK CERTIFICATE

©

C
o
p This Affidavit of Lost Stock Certificate (the “Agreement”) is made and effective [DATE],
y
r BETWEEN: [COMPANY NAME] (the "Company"), a corporation organized and existing
i under the laws of the [STATE/PROVINCE], with its head office located at:
g
h
t
AND: [STOCKHOLDER NAME] (the "Stockholder"), an individual/ a corporation
organized and existing under the laws of the [STATE/PROVINCE], with its head
E office located at:
n
v
i TERMS
s The undersigned Stockholder hereby declares, under penalty of perjury, as follows:
i
o
n
1. The undersigned is the owner of a total of [NUMBER OF SHARES] shares of the Common Stock
C
of [NAME OF COMPANY], Inc., a [STATE WHERE COMPANY INCORPORATED] corporation (the
o
r “Company”).
p
o
r
a 2. The undersigned has examined his, her or its records and, after diligent search, is unable to find
t the certificate or certificates representing such shares (the “Certificates”) and believes that the
i
o Certificates were lost.
n
.
3. The undersigned has not transferred, sold, encumbered, or pledged any of the shares
2
0 represented by the Certificates.
0
2
.
4. The undersigned releases the Company and any successor from any and all liability relating to
A the loss of the Certificates, or the issuance of new Certificates. The undersigned agrees to defend
l
l and indemnify and hold harmless the Company and any successor from any damage or loss caused

r by the loss of the Certificates.

i

Affidavit of Lost Stock Certificate Page 1 of 2

© Copyright Envision Corporation. 2002. All rights reserved. Protected by the copyright laws of the United States & Canada and by international treaties. IT IS
ILLEGAL AND STRICTLY PROHIBITED TO DISTRIBUTE, PUBLISH, OFFER FOR SALE, LICENSE OR SUBLICENSE, GIVE OR DISCLOSE TO ANY OTHER
PARTY, THIS PRODUCT IN HARD COPY OR DIGITAL FORM. ALL OFFENDERS WILL BE SUED IN A COURT OF LAW.

5. In the event of discovery of the original Certificates, the undersigned agrees to return them

promptly to the Company or any successor, marked “CANCELLED.”

IN WITNESS WHEREOF, the parties hereto have executed this Agreement on the date first above
written.

COMPANY STOCKHOLDER

Authorized Signature Authorized Signature

Print Name and Title Print Name and Title

Affidavit of Lost Stock Certificate Page 2 of 2