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Affidavit of Lost or Destroyed Check – Form

Affidavit of Lost or Destroyed Check

Please complete this form to have a replacement check issued for a lost or destroyed check not received or otherwise cashed. * indicates a required field
  • Payee's Name * Required
  • Payee's Mailing Address * Required
  • 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:
  • 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
  • This field is for validation purposes and should be left unchanged.
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