Certificate of Non-Receipt

CERTIFICATE OF NON-RECEIPT

This Certificate of Non-Receipt is executed as of Effective Date: by and between Claimant Name: (hereinafter "Claimant"), whose address is , and Respondent Name: (hereinafter "Respondent"), whose address is .

Recitals

WHEREAS, on or about Issuance Date: , an instrument, notice, payment, or document described as: bearing Reference or Account Number: was issued, transmitted, or otherwise delivered for receipt by Claimant or Claimant's agent; and

WHEREAS, Claimant represents that despite due diligence and repeated attempts (as set forth below), Claimant has not received, accepted, or taken possession of the instrument, notice, payment, or document described above; and

WHEREAS, the parties desire to record and certify the non-receipt for the purpose of creating a written record that may be relied upon by the parties and by third parties as necessary for reissuance, cancellation, replacement, or other remedial action.

NOW, THEREFORE, in consideration of the mutual covenants and agreements set forth herein, the parties agree as follows:

1. Certification of Non-Receipt

Claimant hereby certifies, represents and warrants that as of the Effective Date set forth above, Claimant has not received, accepted, or obtained possession of the instrument, notice, payment, or document identified in the Recitals (the "Item"). This certification is given for the express purposes of establishing non-receipt and to permit Respondent, and any third parties with a legitimate interest, to take such actions as may be necessary in light of non-receipt, including but not limited to reissuance, stop-payment, replacement or declaration of forfeiture, subject to applicable law.

2. Facts and Attempts to Deliver

Claimant states the following facts material to this Certificate of Non-Receipt and the efforts undertaken to obtain the Item:

Delivery methods attempted (check all that apply):

First-class mail
Courier or express delivery
Electronic transmission or email
Personal delivery
Other (specify in attempted delivery details)

3. Effect of Certificate

Upon execution, this Certificate of Non-Receipt constitutes prima facie evidence of non-receipt of the Item by Claimant. Respondent and any other party receiving this Certificate may rely upon the representations contained herein for purposes of reissuance, cancellation, instructing a financial institution, or pursuing any other remedy available under applicable law. This Certificate does not itself effect reissuance or cancellation unless the parties or applicable law require such step and the requisite further procedures are completed.

4. Representations and Warranties

Claimant represents and warrants to Respondent that: (a) Claimant is authorized to make the representations contained in this Certificate; (b) to the best of Claimant's knowledge after reasonable investigation, the Item has not been received, endorsed, negotiated, cashed, or otherwise delivered to or on behalf of Claimant; and (c) the information set forth in this Certificate is true, complete and correct.

5. Indemnity

Claimant shall indemnify, defend and hold harmless Respondent and its officers, directors, employees and agents from and against any and all claims, liabilities, losses, damages, costs and expenses (including reasonable attorneys' fees) arising from or relating to any false representation made by Claimant in this Certificate, provided that Respondent gives Claimant prompt written notice of any claim and permits Claimant to control the defense thereof.

6. Notices

All notices, requests, consents and other communications required or permitted under this Certificate shall be in writing and delivered to the addresses set forth below or to such other address as a party may designate in writing.

7. Governing Law

This Certificate shall be governed by and construed in accordance with the laws of the State of , without regard to its conflicts of law principles.

8. Entire Agreement

This Certificate constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes all prior and contemporaneous agreements, representations and understandings of the parties, whether written or oral, relating to the Item and the non-receipt thereof.

9. Severability

If any provision of this Certificate is held invalid, illegal or unenforceable in any respect, the validity, legality and enforceability of the remaining provisions shall not be affected or impaired.

10. Amendments; Waiver

No amendment, modification or waiver of any provision of this Certificate shall be effective unless in writing and executed by both parties. Failure to enforce any provision shall not constitute a waiver of that provision or any other provision.

11. Counterparts; Electronic Signatures

This Certificate may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one and the same instrument. Facsimile, electronic or scanned signatures shall be binding for all purposes.

12. Execution

Each person signing below certifies and acknowledges that he or she has full power and authority to execute this Certificate on behalf of the party for which he or she signs and that the representations and warranties contained herein are true and correct.

Sign Now