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1. Parties: Identification of the stockholder and the issuing corporation
2. Background: Context of the lost certificate and circumstances of loss
3. Definitions: Key terms used in the document including 'Lost Certificate', 'Shares', and 'Replacement Certificate'
4. Declaration of Loss: Formal statement regarding the lost certificate details, including certificate number, number of shares, and date of issuance
5. Indemnification Provisions: Terms of indemnity provided by the stockholder to protect the company against claims
6. Request for Replacement: Formal request for issuance of replacement certificate and agreement to return original if found
7. Execution: Signature blocks and notarization requirements
1. Search Efforts: Description of attempts made to locate the certificate and confirmation that it cannot be found
2. Bond Provision: Details of surety bond requirements and terms if required by the company
3. Additional Warranties: Extra assurances and representations from the stockholder regarding ownership and validity
1. Schedule A - Certificate Details: Detailed information about the lost certificate including certificate number, number of shares, date of issuance, and registered holder
2. Schedule B - Supporting Documents: Copies of relevant documentation proving ownership and identity
3. Appendix 1 - Police Report: Copy of police report if the certificate was stolen and reported to authorities
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