
AFFIDAVIT OF DISCLAIMER OF INTEREST BY HEIR OF
TANADGUSIX CORPORATION SHAREHOLDER
[AS 13.12.801]
STATE OF _____________________)
___________ JUDICIAL DISTRICT : ss.
or COUNTY OF _________________)
I, ________________________________, swear upon my oath or affirm under
(print full legal name)
penalty of perjury, that to the best of my knowledge, information and belief:
1. _________________________ (“Decedent”) died on ___________________,
(deceased shareholder) (date of death)
as shown by the attached certified copy of the Decedent’s Death
Certificate.
2. Decedent owned ______________ shares of Settlement Common Stock
(number)
(“Stock”) in Tanadgusix Corporation.
3. I am the ______
(relationship to Decedent)
___________________________________ of the Decedent
and may have a present or prospective interest in the Stock which
was owned by the Decedent.
4. Pursuant to AS 13.12.801, I hereby disclaim any and all interest in
the Stock owned by the Decedent.
I agree to defend, indemnify and hold Tanadgusix Corporation harmless from
any claims, demands, fees or expenses that result in any way from the Tanadgusix
Corporation's reliance upon this Affidavit.
DATED at _________________________, on this ____ day of ___________, 20___.
(city, state)
AFFIANT:
Signature:______________________________________________
(sign full legal name in presence of notary public)
Name (please print):_______________________________
Address:_______________________________________
_______________________________________
Telephone No.:_________________________________
SUBSCRIBED AND SWORN TO OR AFFIRMED UPON PENALTY OF PERJURY before me, this
_____ day of _________________, 20___.
______________________________________
Notary Public in and for _____________
My Commission Expires:________________