AFFIDAVIT OF LOST STOCK CERTIFICATE AND INDEMNITY AGREEMENT STATE OF: __________) ) SS COUNTY OF :________) _________________, [Insert Name]

(the Holder), of __________________________ [Insert Address] being duly sworn, does hereby swear and affirm as follows: 1) The Holder is of legal age and is the sole legal and beneficial owner of _______________ [Number] shares of _____ [class] stock, ________ par value, of ______________, a ______ [corporation][limited liability company][etc.] (the Company), represented by Certificate Number[s] _________________________ (the Original Certificate[s]), issued on __________ [date] by the Company in the name of the Holder. 2) The Original Certificate[s] has/have been [lost] [stolen] [destroyed]. 3) The Original Certificate[s] was/were [not endorsed] [endorsed as follows: ________________________________________________________________ _________________________________________________________________ ______________________________________________________________. 4) None of the Original Certificate[s], or any of the Holders rights therein, have, in whole or in part, been assigned, transferred, hypothecated, pledged, gifted, or otherwise disposed of in any manner whatsoever. 5) The Holder is entitled to the full and exclusive possession of the Original Certificate[s], and no other person or entity has any right, title, claim, equity, or interest in, to, or respecting the Original Certificate[s] or the proceeds thereof. 6) The Holder has made the following efforts to locate the Original Certificate[s] [The destruction of the Original Certificate[s] occurred as follows]: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ____. 7) If the Holder ever locates the Original Certificate[s], or if they are otherwise returned to the Holder, the Holder agrees that such Original Certificate[s] has/have no value and that it will surrender those recovered Original Certificate[s] to the Company immediately and without consideration for cancellation.

Affidavit of Lost Stock Certificate and Indemnity Agreement

8) The Holder hereby requests and is making this affidavit (the Affidavit) for the purpose of requesting the Company to issue new or duplicate stock certificates in substitution for the Original Certificate[s]. 9) In consideration of the foregoing, the Holder, for itself, its heirs, legal representatives, successors, and assigns, agrees to: a. Release and forever discharge the Company, its legal representatives, successors, and assigns from any and all claims, suits, and/or causes of action that the Holder may have against the Company in any way relating to or arising out of the Original Certificate[s] and/or the Companys compliance with the request of the Holder in this Affidavit regarding these shares of the Companys stock; and b. Indemnify, hold free and harmless, and protect the Company, its legal representatives, successors, and assigns including, without limitation, its registrar and transfer agent, from any and all losses, damages, liabilities, costs, charges, counsel fees, and/or expenses incurred in connection with or in any way relating to or arising out of: i. The issuance and delivery of [a] new certificate[s]; ii. Any payment, transfer, delivery, exchange, or other act made or done with respect to the Original Certificate[s], whether made or done through accident, oversight, or neglect, or whether made or done on presentation of the Original Certificate[s], without contesting the propriety of such transfer, payment, delivery, exchange, or other act; iii. The Original Certificate[s] and/or the Companys compliance with the Holders request in this Affidavit regarding these shares of the Companys stock; and/or iv. Any breach or violation of any attestation, agreement, representation, or covenant contained in this Affidavit.

[SIGNATURE PAGE FOLLOWS]

IN WITNESS WHEREOF, the Holder has executed this Affidavit on the date set forth below.

Affidavit of Lost Stock Certificate and Indemnity Agreement

Date: __________________

________________________________ _______________ [Holder Name]

State of ____________) )SS County of __________) On this ____ day of ____________, 20___, before me, _____________________________, personally appeared ____________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he or she executed the same for the purpose above stated, and, being by me duly sworn, did depose and state that the statements therein contained are true. WITNESS my hand and official seal. ______________________________ Notary Public My Commission Expires: _____________

Affidavit of Lost Stock Certificate and Indemnity Agreement