Acknowledgement of Receipt of Stock and Consent Form

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This Acknowledgement of Receipt of Stock and Consent Form can be used to recognize receipt of stock between an issuer and purchaser.



The undersigned hereby acknowledges receipt of a photocopy of Certificate No. CS-[Certificate No.] for [No. Purchased] shares of Common Stock of [Company Name], a [State e.g., Delaware] corporation (the “Company”).

The undersigned further acknowledges that the Secretary of the Company, or his or her designee, is acting as escrow holder pursuant to the Common Stock Purchase Agreement that Purchaser has previously entered into with the Company. As escrow holder, the Secretary of the Company, or his or her designee, holds the original of the aforementioned certificate issued in the undersigned’s name.

Dated: [Date this Document is Signed]


[Purchaser Name]

Name: [Purchaser Contact Name]

Title: [Purchaser Contact Title]

[Purchaser Address

Fax: [Purchaser Fax

Email: [Purchaser Email]

[Spouse of Purchaser (if applicable)]

Any [GREEN] highlighted language is intended to be filled in by the user. Any [YELLOW] highlighted language is considered optional or conditional by the attorney community. Consult with an attorney before using this document. This document is not a substitute for legal advice or services. Refer to our Terms of Use for more details.

This form has been prepared for general informational purposes only. It does not constitute legal advice, advertising, a solicitation, or tax advice. Transmission of this form and the information contained herein is not intended to create, and receipt thereof does not constitute formation of, an attorney-client relationship. You should not rely upon this document or information for any purpose without seeking legal advice from an appropriately licensed attorney, including without limitation to review and provide advice on the terms of this form, the appropriate approvals required in connection with the transactions contemplated by this form, and any securities law and other legal issues contemplated by this form or the transactions contemplated by this form.

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