AFFIDAVIT OF LOST PROMISSORY NOTE AND INDEMNITY AGREEMENT STATE OF: __________) ) SS COUNTY OF :________) _________________, [Insert Name]

(the Holder), of __________________________ [Insert Address] being duly sworn, does hereby swear and affirm as follows: 1) The Holder is an authorized officer, representative, or agent of _________________, (the Company), which is the sole holder of that certain promissory note dated as of ____________, in the amount of _________________________________ ($ ___________________) and duly executed by _________________________ (the Borrower) in favor of ________________, as beneficiary (the Original Note). 2) The Original Note has been inadvertently [lost] [stolen] [destroyed]. [The Holder has made the following efforts to locate the Original Note] [The destruction of the Original Note occurred as follows]: _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ ___. 3) The Original Note provides for [monthly] [quarterly] [one lump sum] payment[s] in the amount of ________________________ ($_____________________), [interest payments of $_______________], with such payments [beginning on _______________, _______ and continuing until [the principal and interest have been paid in full][the entire amount becomes due and payable]]. 4) The balance remaining under the Original Note as of _____________________ is ___________________ ($___________________). 5) Neither the Original Note nor any part of the Holders rights therein has, in whole or in part, been sold, transferred, or assigned to any other person or entity. 6) The existence and terms of the Original Note have not at any time been contested by the Borrower and all of the conditions of the loan agreement between the Holder and the Borrower have otherwise been met. 7) (Optional) [A true and correct copy of the Original Note is attached hereto as Exhibit A.] or [A copy of the Original Note is not available, but the Holder hereby states that the terms of the Original Note as stated in this Affidavit are true and correct.]
Affidavit of Lost Promissory Note and Indemnity Agreement

8) If the Holder ever locates the Original Note, or if it is otherwise returned to the Holder, the Holder agrees that such Original Note has no value and that it will surrender that Original Note to the Borrower immediately and without consideration. 9) The Holder hereby requests and is making this Affidavit for the purpose of requesting the Borrower to execute a duplicate note in substitution for the Original Note. 10) In consideration of the foregoing, the Holder, for itself, its heirs, legal representatives, successors, and assigns, agrees to: a. Release and forever discharge the Borrower, its legal representatives, successors, and assigns from any and all claims, suits, and/or causes of action that the Holder may have against the Borrower in any way relating to or arising out of the Original Note and/or the Borrowers compliance with the request of the Holder in this Affidavit regarding this Original Note; and b. Indemnify, hold free and harmless, and protect the Borrower, its legal representatives, successors, and assigns including, without limitation, its registrar and transfer agent, from any and all losses, damages, liabilities, costs, charges, counsel fees, and/or expenses incurred in connection with or in any way relating to or arising out of: i. The issuance and delivery of a new note; ii. Any payment, transfer, delivery, exchange, or other act made or done with respect to the Original Note, whether made or done through accident, oversight, or neglect, or whether made or done on presentation of the Original Note, without contesting the propriety of such transfer, payment, delivery, exchange, or other act; iii. The Original Note and/or the Companys compliance with the Holders request in this Affidavit regarding the note; and/or iv. Any breach or violation of any attestation, agreement, representation, or covenant contained in this Affidavit.

IN WITNESS WHEREOF, the Holder has executed this Affidavit on the date set forth below.

Affidavit of Lost Promissory Note and Indemnity Agreement

Date: __________________ ________________________________ Signature of _______________ [Holder Name]

State of ____________) )SS County of __________) On this ____ day of ____________, 20___, before me, _____________________________, personally appeared _________________, personally known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the foregoing instrument, and acknowledged to me that he or she executed the same for the purposes above stated, and, being by me duly sworn, did depose and state that the statements therein contained are true. WITNESS my hand and official seal. ______________________________ Notary Public My Commission Expires: _____________

Affidavit of Lost Promissory Note and Indemnity Agreement

[EXHIBIT A] [Attach copy of Original Note, if available]

Affidavit of Lost Promissory Note and Indemnity Agreement