AFFIDAVIT FOR LOST, STOLEN, DESTROYED STOCK CERTIFICATE

State 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
certificates.

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.

Dated:_____________________
                                  ____________________
                                     [Signature]
[Jurat]