FORM D Instructions: This form of affidavit is to be used to effect a change in the ownership of record of securities already issued and registered, where no change of beneficial ownership is contemplated. IN THE MATTER OF THE SECURITIES ACT - and -IN THE MATTER OF (See over, instructions No. 1) AFFIDAVIT OF (See over, instructions No. 2) I, of the (See over, instructions No. 3) of in the of make oath and say as follows that: 1. The applicant is the registered holder of (See over, instructions No. 4) of (See over, instructions No. 5) as bailee or trustee for (See over, instructions No. 6) MG-3478
2. The applicant became entitled to possession of such securities on the day of , 20 pursuant to or in connection with (See over, instructions No. 7) 3. The applicant believes that a change in the ownership of record of said securities is now warranted for the following reasons or change of circumstances: 4. The applicant has no personal or beneficial interest in said securities. 5. 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) Note: A copy of this affidavit is to be sent to the Securities Commission within 5 days of its receipt by the transfer agent.
Instructions: ALL PARAGRAPHS ON THIS FORM MUST BE ANSWERED 1. Indicate the full name of the person or company who issued the registered securities. 2. Indicate the name of the individual making and signing the affidavit. 3. Where the applicant is a body corporate, indicate the office and authority of the person making and signing the affidavit. 4. State the overall quantity or value of ALL the securities registered in the name of the applicant and give a brief description of their nature, rights and preferences. 5. Indicate the full name of the person or company who issued the registered securities. 6. Where the current registration was made for the benefit of individual beneficiaries or a class thereof, give the name of such beneficiaries or a brief description of the class and the specific quantity or value of such securities as each or some of such beneficiaries are now entitled to under distribution. Where the current registration was made on behalf of principals, give the name and address of such principals and the specific quantity or value of such securities as are held for each such principal who is now entitled to have said securities registered under his name. 7. State the nature and particulars of the transaction, rights or authority in connection with or pursuant to the exercise or satisfaction of which the securities were originally transferred to and registered under the name of the applicant. 8. Occasionally the applicant, as well as being a trustee, will also be a beneficiary of the trust. In that case paragraph 4 of the affidavit must be amended by adding at the end the words "except as follows" followed by an explanation of the applicant's beneficial interest.
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.