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STATE OF________________)
                                                  )  SS:
COUNTY OF_____________)

LOST MEMBERSHIP CERTIFICATE AFFIDAVIT

The undersigned, being duly sworn, deposes and says as follows:

1. The undersigned is a member of ______________________, a limited liability company formed under the laws of the state of _______________ (the "LLC").

2. Certificate number ___ representing _______ units of membership interest of the LLC has been lost, stolen or destroyed and cannot be produced or found.

3. To induce the LLC to issue a substitute certificate for said membership interest, the undersigned, for himself, and his successors and assigns, hereby represents, warrants and covenants that the undersigned is the sole owner of the membership interest represented by such certificate, that such membership interest is not subject to any lien, encumbrance, claim or right or adverse interest to the undersigned whatsoever.

4. The undersigned hereby agrees to indemnify, protect, defend and save harmless the LLC and transfer agent, from any liability, action or the pursuit of any right or purported right by or of any person with respect to the issuance of a replacement certificate or certificates, and in any manner connected therewith, and does for himself, and his successors and assigns, hereby release and remit any claim or right of any kind the undersigned may hold now or ever hold against the LLC in, to or in respect to said issuance.

Dated: ________________

_________________________________
(Name as shown on the records of the LLC)

STATE OF________________)
                                                  )  SS:
COUNTY OF_____________)

I, ________________, in and for said County and State, do hereby certify that __________ personally known to me as the person whose name is subscribed above, did acknowledge before me that he did execute the within instrument as his free and voluntary act for the uses and purposes therein set forth.

___________________________________
Notary Public

{SEAL}