Desktop Schools Popup

Series 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: _______________________________________________________________________

 

       
 

The foregoing was acknowledge before me this _______ day of _____________________, 2_____

by __________________________________,

under the laws of Minnesota.

 

____________________________

Signature of Notary Public

   

Office use only: Vendor #: _____________

 

 

 

 

 

 

 

 

 

Procedures/704.2.5P/5-1-12