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. Close How is the information I enter in this webform being protected? Any information you send using this webform is protected in transit with SSL encryption.Visit our Privacy Statement, opens in a new window to learn more about how your personal information is handled and protected. Information submitted in this webform is secure. Learn More about sending data over email. This iframe contains the logic required to handle Ajax powered Gravity Forms.