Affidavit of Lost, Stolen or Destroyed Check

Notarization is required to have a replacement check issued. Please fill out this document, have it notarized, and upload it below, or mail to:

Sno-Isle Libraries
Accounting Staff
7312 35th Ave NE
Marysville, WA 98271-7417

The notarized document and the below form must be submitted for a replacement check to be issued for a lost, stolen or destroyed check not received or otherwise cashed. If you have questions, please email us.

"*" indicates required fields

Payee's Name*

First Last

Payee's Mailing Address*

Street Address Address Line 2 City State

ZIP Code

Check Amount*

Submission Method of Notarized Document*

I will upload the document

I will mail the document to the above address

Notarized Affidavit of Lost/Destroyed Check*

Only accepting jpg, gif, png, or pdf files 5MB or smaller.

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

Affidavit*

By this Affidavit, I, the "Payee" named above, affirm under oath that I am the named payee of the check identified above, that I have not cashed or deposited the check identified above, and that I have never benefited and do not plan to benefit in any manner from said check. I further affirm that, to the best of my knowledge, the check identified above ("the original check") has been:

Lost, misplaced or stolen before being delivered to me,

Received by me but has since been lost, misplaced, destroyed or stolen,

Cashed by someone other than me, without my permission or endorsement.

Electronic Signature*

I provide this sworn Affidavit so that a replacement check may be issued to me. In consideration for the issuance of a replacement check, I agree that if the original check should ever come into my possession, I will not allow it to be cashed or deposited and I will either destroy it, or deliver it immediately to Sno-Isle Libraries. I acknowledge that if I deposit or cash the check listed above that I may be subject to prosecution, and that Sno-Isle Libraries may take steps to recover any and all amounts to which I was not entitled.

Your Full Name*

First Middle Last

Email Address*

Comments

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Affidavit of Lost, Stolen or Destroyed Check

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