STATE OF FLORIDA DISBURSEMENT UNIT Affidavit for Stop Payment Request I, _______________________________ _____________________________________ (Last Name, First Name, Middle Initial) residing at (address) In the City of_________________ County of_____________ and the State of__________________ Case Number(s)_____________________________________ Hereby request a STOP PAYMENT -- Please check reason below for the stop payment request. Enter information for ONE CHECK only. A COMPLETED, SIGNED, and NOTARIZED AFFIDAVIT MUST BE COMPLETED FOR EACH LOST, STOLEN, or STALE-DATED CHECK. Lost Check *Stolen Check Stale-Dated Check Check #_________________ in the amount of $__________Dated: _______ *If the check was stolen a police report needs to accompany this affidavit. Return Form to: STATE OF FLORIDA DISBURSEMENT UNIT (SDU) P.O. BOX 7436 TALLAHASSEE, FL 32314 I offer the following explanation concerning the status of this check. (If none state ‘none’) _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ I have completely and accurately reported to the SDU all the information, knowledge and facts that I possess concerning this check and should anything else concerning this check come to my attention, I will immediately report the information to the SDU. I understand that if I receive the missing check at any time during this process, and I deposit or cash the check, then I will be held liable for the refund of the check and any fees assessed. In addition, I understand that this affidavit must be COMPLETED, SIGNED, AND NOTARIZED, and RETURNED TO THE SDU BEFORE A CHECK CAN BE REISSUED. IF THE CHECK WAS STOLEN, A POLICE REPORT MUST ACCOMPANY THIS AFFADAVIT. This affidavit is made voluntarily and for the purpose of establishing the claim of the referenced check. My signature below indicates I have read and agree to the terms of the process discussed above. (NOTARY REQUIRED) SSN Number Requestor Signature Sworn to and subscribed before me this ______ day of _______, 20_____, by ____________ who is personally known or has provided ________________________ as identification. Date Notary Public (Area Code) Home Phone (Area Code) Work Phone My commission expires: ________________________________ Rev 9/2003 American LegalNet, Inc. www.FormsWorkflow.com