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STATE DISBURSEMENT UNIT Customer Service: (877) 225-7077 |
AFFIDAVIT OF LOST, MISSING, OR STOLEN
CHECK
I,
_________________________________________________________, being first duly sworn upon oath,
depose and
state the following:
1.
A check (s) was
issued by the ILLINOIS STATE
DISBURSEMENT UNIT , which is identified as follows:
Affidavit may only be used for up to two checks per docket number.
Issuing County:
Docket Number:
| Check Number: |
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| Amount: |
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| Payable To: |
2. That the
above-described check HAS 
HAS NOT been received by me.
3.
That the above-described check has been
LOST STOLEN MISSING DESTROYED
4. That by this affidavit I am requesting that
the ILLINOIS STATE DISBURSEMENT UNIT
place a STOP PAYMENT
on the above-described
check and to reissue a replacement check.
I further understand that under no circumstances
should I present the
above described check (s) for payment if it should come into my possession after
the filing of this
affidavit.
5. I,
_________________________________________, further understand that by
presentation of this affidavit and the
issuance of a replacement check by the
Illinois State Disbursement Unit that I
can be held legally liable both under
criminal and civil laws of the State of
Illinois if I should attempt to cash or present the above described
check(s) to
any bank, financial institution, currency exchange, or any other third
party.
____________________________ Subscribed
and sworn to before me this
Signature
of Affiant
_______day of_____________, 20_____,
_________________________________
Notary Public
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Original notarized form MUST be mailed
into the ILSDU.Faxed copies will not be accepted. |
The information required to
submit the above affidavit of a potential lost, missing or stolen check can be
obtained by
calling Illinois State Disbursement Unit Customer Service at (877)
225-7077. After you complete the form
mail it to
the Illinois State Disbursement Unit at the above address.