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 a required field

Payee's Name * Required
First Last
Payee's Mailing Address * Required
Street Address Address Line 2 City State
ZIP Code
Check Amount * Required
Submission Method of Notarized Document * Required
- I will upload the document
- I will mail the document to the above address
Notarized Affidavit of Lost/Destroyed Check * Required
Only accepting jpg, gif, png, or pdf files 5MB or smaller.
Accepted file types: jpg, gif, png, pdf.
Maximum file size - 5 mega bytes.
Affidavit * Required
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 * Required
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 * Required
First Middle Last
Email Address * Required
Email
This field is for validation purposes and should be left unchanged.

This information will be submitted via email. .

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Affidavit of Lost, Stolen or Destroyed Check

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