Impressed
Stamp
216

insert here
full Name, )
Address, and
Description f
of Declarant

1

SECRETARIAL PRACTICE

FORM No. 7.
DECLARATION AND INDEMNITY FOR DUPLICATE
CERTIFICATE,
THe ‘A’ ComPANY, LIMITED,
Registered Office: London Wall, London.
[b, A. B., of oer. AO SOlemnly and sincerely
declare that I am the Registered Proprietor of... in the ‘A’
COMPANY, LIMITED, and that the Certificate numbered .... in respect of
the said ........ has been mislaid, destroyed or lost; and that I have made,
or caused to be made, diligent but unavailing search for the same; and 1
further declare that I have not sold, pledged, or in any other way
encumbered or disposed of the said... evens
And I make this solemn Declaration conscientiously believing the
same to be true, and by virtue of the provisions of the Statutory
Declarations Act, 1835.
... this | 4B.
Declared at —— ne
Before me, X. Y.

x

This Declaration must be made and signed either befove a Justice
of the Peace, a Notary Public, or a Commissioner to administer
oaths in the Supreme Court of Judicature in England, and must
bear a 2s. 6d. impressed Stamp
I, the above-named A. B., do hereby request The ‘A’ CoMPpaNY,
LiMITED, to issue to me a duplicate Certificate of the ...... above
mentioned, notwithstanding the loss of the Certificate numbered ............
and in consideration of the Company so doing, I hereby, for myself,
my heirs, executors or administrators, indemnify the said Company
against all claims and demands, moneys, losses, damages, costs, and
expenses which may be brought against, or be paid, incurred, or sus-
tained by the said Company by reason or in consequence of the said
Certificate having been mislaid, destroyed or lost, or by reason or in
consequence of the issuing to me of the said duplicate Certificate or
otherwise howsoever in relation thereto respectively.

I further undertake and agree, if the said Certificate shall hereafter be
found, forthwith to deliver up the same or cause the same to be delivered
up to the ‘A’ Company, Limited, their successors and assigns without
cost, fee or reward.
Signed by the said 4.B.

in the presence of

Witness’s name | X.Y. Z
and Address |... ...

Note..—The Indemnity must bear a 64. Stamp, either impressed or
adhesive. The Company may (and will if the account be of any
magnitude) require a guarantee or indemnity by a person of standing
as follows: —

And I... of... concur in the above request and guarantee the

performance by the said ............ of the above undertaking.
(RY TL 0 1377.2)

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