If you are unable to locate some or all of the share certificates representing your shares of common stock of Benj. Franklin Federal Savings and Loan Association, you must complete this certification. Your signature must be notarized.
The certificate(s) representing the following shares of common stock has/have been lost, stolen, seized, or destroyed:
Number of Shares:
(1) I hereby certify that: (a) I have made or caused to be made a diligent search for such share certificate(s) and have been unable to find or recover it/them; (b) I have not sold, assigned, pledged, transferred, deposited under any agreement, or hypothecated the shares of Benj. Franklin Federal Savings and Loan Association common stock represented by such share certificate(s), or any interest therein, or assigned any power of attorney or other authorization respecting the same that is now outstanding and in force, or otherwise disposed of such share certificate(s); and (c) no person, firm, corporation, agency, or government, other than me, has or has asserted any right, title, claim, equity, or interest in, to, or respecting such shares of Benj. Franklin Federal Savings and Loan Association common stock.
(2) I also agree, in consideration of compliance with the foregoing request, (a) to surrender immediately to Benj. Franklin Federal Savings and Loan Association or its agent the lost share certificate(s) should it/they hereafter come into my possession or control and (b) to indemnify and hold harmless the FDIC and any person or entity now or hereafter acting in any capacity for the FDIC from and against any and all liability, loss damage and expense, including attorneys’ fees, suffered or incurred by any of them regarding the payment of the liquidating distribution to the person executing this Affidavit of Lost, Missing or Destroyed Certificate(s).
STATE OF __________)
COUNTY OF _________)
____day of __________, 20__, before me, a Notary Public duly authorized
in the state and county named above to take acknowledgements, personally appeared
_________________________, known to me to be the individual who executed the
IN WITNESS WHEREOF, I hereunto set my hand and official seal.