AFFIDAVIT

AS TO LOST STOCK CERTIFICATE

STATE OF:

COUNTY OF:

I, ______________, BEING DULY SWORN DEPOSES AND SAYS THAT I/WE ARE THE

DEPONENT AND RESIDE AT: ______________________________________________________________________________

(STREET NUMBER) (CITY) (STATE & ZIP)

THAT DEPONENT IS OR ARE THE BENEFICIAL HOLDERS OF ___________

SHARES OF THE CAPITAL STOCK OF ______________

DESCRIBED AS FOLLOWS: