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