© Copyright Envision SBS. 2007. 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.
Page 1 of 1
CONFIRMATION
OF
LOST
STOCK
CERTIFICATE
This Confirmation of Lost Stock Certificate (the “Agreement”) is made and effective [DATE],
BETWEEN:
[YOUR COMPANY NAME] (the "Company"), a corporation organized and existing under the laws of the
[State/Province] of [STATE/PROVINCE], with its head office located at:
[YOUR COMPLETE ADDRESS]
AND:
[STOCKHOLDER NAME] (the "Stockholder"), an individual/ a corporation organized and existing under the laws
of the [State/Province] of [STATE/PROVINCE], with its head office located at:
[COMPLETE ADDRESS]
TERMS
The undersigned Stockholder hereby declares, under penalty of perjury, as follows:
The undersigned is the owner of a total of [number of shares] shares of the Common Stock of [name of
company], Inc., a [state where company incorporated] corporation (the “Company”).
The undersigned has examined his, her or its records and, after diligent search, is unable to find the certificate
or certificates representing such shares (the “Certificates”) and believes that the Certificates were lost.
The undersigned has not transferred, sold, encumbered, or pledged any of the shares represented by the
Certificates.
The undersigned releases the Company and any successor from any and all liability relating to the loss of the
Certificates, or the issuance of new Certificates. The undersigned agrees to defend and indemnify and hold
harmless the Company and any successor from any damage or loss caused by the loss of the Certificates.
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