Adopted: August 2005
Revised: June 2007
Download 704.2.5P - Affidavit of Lost, Destroyed or Stolen Accounts Payable Check
The Undersigned states as follows:
Independent School District 196, Rosemount, Minnesota, issued its original check number ______________ in the amount of $_________, payable to the order of the Undersigned.
Please initial appropriate box.
[ ] The original check was lost, mislaid, destroyed, or stolen after the Undersigned received it. I make this affidavit to induce the issuance to me of a duplicate check to take the place of the lost, mislaid, destroyed or stolen check. Should said lost, mislaid, destroyed or stolen check, at any time, come into my hands, I will not attempt to cash or deposit said check and will immediately deliver it to the Accounts Payable Department at the District Office.
[ ] The original check was reportedly lost, mislaid, destroyed, or stolen before the Undersigned received it. I make this affidavit to induce the issuance to me of a duplicate check to take the place of the lost, mislaid, destroyed or stolen check. Should said lost, mislaid, destroyed or stolen check, at any time, come into my hands, I will not attempt to cash or deposit said check and will immediately deliver it to Accounts Payable Department at the District Office.
[ ] The original check purports to bear the Undersigned’s signature or endorsement, and the Undersigned expressly denies, disaffirms and disavows the signature or endorsement.
Company representative (please print): _______________________________________________________
Company representative signature: _____________________________________ Date:
Company name and phone number:
Street address: ____________________________________________________________________________
City, state, zip code: _______________________________________________________________________