Shareholder Affidavit

In the event that the Department receives unclaimed property which is reported in the name of a corporation which has been dissolved and the documentary evidence establishing the ownership interest of the respective shareholders has been lost or destroyed, the claimant may file an affidavit which identifies the shareholders of the dissolved corporation and the respective ownership interest of each shareholder. The following is a recommended form for the affidavit. The form affidavit may be modified to meet the specific facts of the case. Nothing in this rule shall be interpreted as foreclosing the option of the Department of requiring live testimony in order to establish the respective ownership interest in unclaimed property which is reported in the name of a dissolved corporation should the Department determine that the circumstances warrant live testimony. The recommended form for the affidavit is as follows:

AFFIDAVIT

STATE OF )

COUNTY OF )

After being duly sworn, the affiant states as follows:

1. My name is ________________________. I have personal knowledge of the matters set forth in this affidavit, and if called to testify would do so as set forth herein.

2. _________________(hereinafter Corporation) is currently dissolved.

3. I have made a good faith search for the stock certificates of the Corporation and have not been able to locate the original stock certificates or copies thereof.

4. I have made a good faith search for any documentation of the Corporation which would reflect the stock ownership of the Corporation and

Last Revised 10-13-2010 9 have not been able to locate the original of any such documentation or copies thereof.

5. To my knowledge none of the documents referred to in paragraphs 3. and 4. herein have been destroyed in bad faith in an effort to conceal the ownership of the Corporation.

6. To my knowledge the ownership interest of the Corporation was as follows: ______________________________________

__________________________________________________________________________________________________________________

SWORN to and subscribed before me this _______, day of ________, A.D.

_______________________

(Signature of Notary Public)

______________________________________

(Print, Type, or Stamp Commissioned Name of Notary Public)

Personally Known ______________________________ OR

Produced Identification __________________________

Type of Identification Produced ___________________

Specific Authority 717.138 FS. Law Implemented 717.124, 717.126 FS. History–New 11-6-96, Formerly 3D-20.0025.