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) 
Dated this coc GAY Of coors IQs