FORM A Instructions: This form of affidavit is to be used in cases of gifts inter vivos of securities already issued and registered where the applicant seeks a registration of the transfer of ownership. IN THE MATTER OF THE SECURITIES ACT - and -IN THE MATTER OF (Name of Issuer of Security) AFFIDAVIT OF I, (State Full Name) of (State Full Address) make oath and say as follows that: 1. was the owner of (State full description of security including certificate(s), number(s) and registration(s)) 2. Said security was given by me (us) (it) on the day of , 20 to (State Full Name and Address of Transferee) upon which time the gift became absolute and such gift was not made upon the existence or expectation of any term, condition, restriction or warranty or upon the existence or expectation of any consideration, value or services the benefit of which did or were to accrue to the donor or any other person or company other them the transferee. MG-3476
3. had full title to said security at the time of the gift and no other person or company was beneficially entitled thereto or had a beneficial interest therein immediately prior to such time. 4. I have such knowledge of the matters herein deposed to and no material facts having any bearing on the foregoing have been omitted or misrepresented. ) SWORN BEFORE ME at the of ) in the of ) ) , 20 . ) A Commissioner for Oaths or Notary Public (signature) Where the applicant is a body corporate, indicate the office and authority of the person making and signing the affidavit. Note #1: This affidavit is to be taken by the donor or, if the donor is a company, one of its officers. At the beginning of paragraphs 1 and 3 insert the word "I" or the name of the company. If the shares in question were jointly owned, the affidavit may be taken by one of the donors and the appropriate changes made in paragraphs 1 and 3. Note #2: A copy of this affidavit is to be sent to the Securities Commission within 5 days of its receipt by the transfer agent.
You are being directed to the most recent version of the statute which may not be the version considered at the time of the judgment.