I, ______________________ son of / daughter of / wife of __________________, aged ______ years, resident of __________________________________ do solemnly and sincerely swear and state as under:
That I am the shareholder of ____________________________ (mention here the name of the company) and hold _________________________ shares of the Nominal value `______ each as per the details below:
| Folio No. | No. of Shares Held | Share Certificate No. | Distinctive No. of Shares Held |
|---|---|---|---|
That the said share certificate covering that said shares has been lost / misplaced / not received and it is not in my possession.
That I have not transferred the said shares or any of them in favour of any other person and I have not executed an instrument of transfer for the said shares in favour of any person.
I hereby request the Board of Directors of __________________________ (mention here the name of the company) to issue to me the duplicate share certificated for the said shares.
I confirm that if original share certificate(s) is / are found, I will surrender or cause it / them to be surrendered to the Company.
Sworn on this ____________ day of ___________ 20XX at _______________ (Place).
Signature of the Deponent
Before me:
(Signature of the person whom the Affidavit is sworn)
VERIFICATION
I solemnly affirm that what is stated hereinabove is true to the best of my knowledge and belief, and that no part thereof is incorrect.
Place:
Date:
Signature of the Deponent