Declaration Regarding Lost Share Certificate

IN THE MATTER OF share certificate number [Number of Lost Share Certificate] (the
"Certificate") for [Number and Class of Shares (ie. 100 Common)] shares (the "Shares") in the
capital stock of [Name of Corporation whose Share Certificate has been Lost] (the
“Corporation”) registered in the name of [Name of Shareholder] (the “Shareholder”).

I, [Name of Officer Signing on behalf of Shareholder], of the City of [City of Residence of

Shareholder], in the State of [State of Residence of Shareholder].

DO SOLEMNLY DECLARE THAT:

1. I am the [Capacity of Title of Person Signing Declaration (ie. President)] of the

Shareholder and as such, have knowledge of the matters hereinafter deposed to.

2. The Shareholder is the registered owner of the Shares represented by the Certificate. The
Shares are registered in the name of the Shareholder on the books and registers of the
Corporation.

3. The Shareholder has not sold, transferred, assigned, pledged, hypothecated or otherwise
encumbered or disposed of the Shares, nor has the Shareholder in any way divested itself
or been divested of the absolute ownership thereof.

4. The Certificate has been mislaid, lost, stolen or destroyed so that the same cannot be
found or produced. At the time when it was mislaid, lost, stolen or destroyed, the
Certificate had not been endorsed for transfer.

5. I make this solemn declaration for the purpose of inducing the Corporation to replace or
cause to be replaced the Certificate, and to issue or cause to be issued a new certificate or
certificates in my name in lieu of the Certificate, and I hereby declare that if the
Certificate comes into the Shareholder's possession or control ormy possession or control,
I will immediately surrender the Certificate to the Corporation.

Declared on [Date (ie. July 31, 2002)].

[Name of Officer Signing on behalf of Shareholder]

District of [District]:

On [Date (ie. July 31, 2002)], before me personally appeared [Name of Officer Signing on
behalf of Shareholder], to me known, who, being duly sworn, did say that he is the
[Capacity of Title of Person Signing Declaration (ie. President)] of [NAME OF
ASSIGNOR], and that the foregoing Declaration Regarding Lost Share Certificate was
signed and sealed on behalf of the said corporation by authority of its Board of Directors,
and acknowledged said instrument to be the free act and deed of said corporation.

Notary Public