Declaration of Loss – Share Certificate
Declaration recording the loss of a share certificate.
What this format contains
Declaration of Loss of Share Certificate
Full name and address of the shareholder: Name: [SHAREHOLDER NAME] Address:
Number of shares held by the shareholder: Number of shares: [FIGURE]
Distinctive numbers of the shares in respect of which certificate(s) is/are lost: From:_____ to To:__________
Date when the share certificates were lost or found to be missing: Date:
Full statement of the circumstances of loss of the share certificate(s):
Were any signed transfer forms attached to the missing share certificate(s)? If yes, give full particulars:
Were the shares sold, mortgaged, pledged, or otherwise disposed of either by the shareholder, applicant, or by any other person? If yes, give full particulars:
Was diligent search made for the missing certificate(s)? (Yes/No and details of search)
Signature: ___________________________
Date: _______________Place: [PLACE]