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Series 704.4.2P - Affidavit of Lost, Destroyed or Stolen Payroll Check 

Adopted: August 2005
Revised

 

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.

EMPLOYEE:  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 Payroll 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 Payroll 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.

Employee name (please print): _______________________________________________________________

Employee signature: ________________________________________ Date of signature:                 

Street address: ____________________________________________________________________________

City, state, zip code: _______________________________________________________________________

Employee number: ______________________________ Location: ________________________________

The foregoing was acknowledged before me this _______ day of ________________, 2_______

by__________________________________________, under the laws of Minnesota.

________________________________

Signature of Notary Public

Procedures/700 Series/704.4.2P/8-31-05