IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT, BREVARD COUNTY, FLORIDA IN THE COUNTY COURT, BREVARD COUNTY, FLORIDA DIVISION CIVIL CRIMINAL LOST CHECK AFFIDAVIT JUVENILE TRAFFIC PLAINTIFF CASE NUMBER 05 - - - - XXXX-XX BAR CODE LABEL CLOCK IN DEFENDANT LOST CHECK INFORMATION NAME OF PAYEE CHECK NUMBER DATE OF CHECK AMOUNT OF CHECK STATE OF FLORIDA COUNTY OF BREVARD BEFORE ME this day personally appeared _________________________________________________, who, being duly sworn, deposes and says that to this date, he/she has not received the above referenced check. If said check is received after the signing of this affidavit, it will be mailed immediately to the Clerk's office. AFFIANT SIGNATURE AFFIANT ADDRESS PHONE NUMBER SWORN to and SUBSCRIBED before me this __________ day of ________________________ 20_____ . NOTARY PUBLIC/DEPUTY CLERK STOP PAYMENT ISSUED TO BOOKKEEPING _________________ REPLACEMENT CHECK NUMBER __________________________ REPLACEMENT CHECK DATE _____________________________ CHECK CASHED____________________ LAW 138 Rev. 09/2005 American LegalNet, Inc. www.FormsWorkflow.com