AFFIDAVIT FOR LOST, STOLEN, DESTROYED STOCK CERTIFICATE

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
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]

AFFIDAVIT OF NO LIEN

STATE OF___________________
COUNTY OF__________________

Before me, a duly commissioned Notary Public within and for
the State and County aforesaid, personally appeared________
_________who, after being duly sworn as required by law,
deposes and says:

1. That he is the ___________________[title] of __________
________________________________[firm].

2.That_____________________[said firm] is the owner of the
improved property known and legally described as follows:

SEE EXHIBIT “A” ATTACHED HERETO
or
[set forth legal description]

3. That ___________________is not the subject to any
bankruptcy, creditor’s reorganization or insolvency
proceeding and none are pending, contemplated or threatened.

4. That ____________________has possession of the
property and that there is no other person in possession
who has any right in the property.

5. That there are no unrecorded labor, mechanic’s or
materialmen’s liens against the property and no material
has been furnished or labor performed on the property which
has not been paid in full.

6. That there are no unrecorded easements, liens of
assessments for sanitary sewers, paving or other public
utilities against said property.

7. That there are no claims whatsoever of any kind or
description against any fixtures or equipment located on
the said premises.

8. That there are no existing contracts for sale, options
to purchase or unrecorded deeds or mortgages existing
against said property.

9. That this affidavit is made for the purpose of_________
__________________________________________________________
_________________________
[signature]
Subscribed and sworn to before me this ___ day of _______,
19__.
______________________
My commission expires________ NOTARY PUBLIC