Affidavit of loss check

Check number: ____________________

Account number: ____________________

(a copy of the remitter's copy may be attached)

the time the claim is asserted; or
the 90th day following the date of the check, in the case of a cashier's check or teller's check or the 90th day following the date of acceptance in the case of a certified check.

I agree to provide reasonable identification if so requested by the bank.

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Signature of claimant

Declaration of Loss
I, ____________________________________________________, was the drawer/payee (circle one of these choices if the item was a certified check) of the above-described certified check OR the remitter/payee of the above-described cashier's check or teller's check (circle one of these choices if item was a cashier's check or teller's check). I lost possession of the check. The loss of possession was NOT the result of a transfer of the check or a lawful seizure and I cannot obtain possession of the check because

the check was destroyed;
the check is in the wrongful possession of an unknown person;
the whereabouts of the check cannot be determined; or
the check is in the wrongful possession of a person that cannot be found or is not amenable to service of process.

The following is a brief description of the circumstances surrounding the loss, destruction, or theft of the cashier's check, teller's check or certified check:
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The statements made herein are made under penalty of perjury and I warrant them to be true and correct.

I understand that if this claim is paid and the check is later presented for payment by a person having the rights of a holder in due course, I am obliged to either refund the payment to the bank if the check is paid or pay the amount of the check to the person having rights of a holder in due course if the check is dishonored.

Dated this ___________ day of _____________________, ___________.

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Signature of Claimant