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 First Last Payee's Mailing Address * Required Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Check Amount * RequiredAffidavit * RequiredBy 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 * RequiredI 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 CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
