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(Loss of Negotiable Instrument)
---------- COURT OF THE STATE OF ---------- COUNTY OF ----------
WHEREAS, one Principal of this Bond is Plaintiff in the above-
entitled action to recover against Defendant the sum of ----------
dollars ($----------), which is the principal sum and accrued
interest of a check [or, note, draft], of [date], held by
Plaintiff and on which Defendant is obligated as Drawer [or,
Drawee, Maker]; and
WHEREAS, Plaintiff has sworn to the Court that the instrument
cannot be presented because it has been lost [or, stolen,
destroyed), and Plaintiff has established before the Court the
terms and conditions of the instrument, Plaintiff's ownership
thereof, and the reasons preventing the production of the
instrument in Court.
THEREFORE, [Plaintiff], as Principal, and [name], as
Surety, whose principal place of business is located at [address]
(collectively called Obligor), are hereby firmly bound to the
following parties to the instrument: [name] and [name]
(collectively called Obligee), in a sum sufficient to indemnify
Obligee under the conditions of this Bond, not to exceed the sum of
---------- dollars ($----------) in the case of the Surety.
The conditions of this Bond are:
1. Obligor shall deliver the instrument to Obligee
for cancellation should it come into the hands
or control of Obligee.
2. Obligor shall indemnify and hold Obligee harmless
from all other claims and actions based upon
the instrument and from all liabilities,
damages, expenses, and counsel fees resulting from
such claims or actions.
Agreed to this [dated].
This Bond is accepted this [dated]
ACKNOWLEDGEMENT BY NOTARY PUBLIC
State of ________)
On ________, before me, ________, Notary Public, personally appeared ________, who proved to me on the basis of satisfactory evidence to be the person(s) whose names(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies) and that by his/her/their signatures on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under the PENALTY OF PERJURY under the laws of the State of _________ that the foregoing paragraph is true and correct.
WITNESS my hand and official seal.
Name of Notary
My Commission Expires