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

State 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]