Solano — Unclaimed Funds: Lost/Stolen Check Affidavit (case related)

Source: https://solano.courts.ca.gov/system/files/lost-check-affidavit-case.pdf

LOST/STOLEN CHECK AFFIDAVIT

I, ____________________________________, ______________________________ declare that: (Type or Print Name) (Tax ID/Social Security Number)

1. The Superior Court of California, County of Solano (“Court”) issued a check payable to my order
in the amount of $__________ on _________________ as a refund in connection with a court
case. This check is referred to as the “Missing Check” below.

2. I am the legal owner or entitled to possession of said check and said check has been (destroyed)
(lost) and the facts of such (destruction) (loss) insofar as known to me are as
follows:______________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

3. I further agree to indemnify and hold the State, the Court, and its agents, officers, and employees
harmless for all personal losses and expenses I incur, including all attorney’s fees related to the
Missing Check.

4. I agree that, if a new check is issued to me in lieu of the Missing Check, and if the Missing Check
hereafter is placed in my possession, I will not negotiate, deposit or cash said check. I will not
authorize any third party to endorse the Missing Check on my behalf.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date: __________________ Place: _____________________________________

Signature of Declarant: _________________________________________________

Mailing Address of Declarant: ____________________________________________