Print Form Affidavit of Lost, Missing or Stolen Check STATE OF ILLINOIS COUNTY OF COOK } Clear Form (12/11/06) CCSD 0693 (This form replaces CCG 0693) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS ss: AFFIDAVIT OF LOST, MISSING OR STOLEN CHECK (COOK COUNTY CHECKS) CASE NUMBER(S) ____________________________________________ SOCIAL SECURITY NO. ___________________ I, _____________________________________________, being first duly sworn on oath, state the following: (Name of person making affidavit) 1. I am the Petitioner in the above mentioned case number(s) filed in the Circuit Court of Cook County. 2. I reside at ______________________________________________________________________________________. 3. My telephone number 4. I receive child support through the State Disbursement Unit pursuant to an Order for Support. 5. Checks were issued by DOROTHY BROWN, Clerk of the Circuit Court of Cook County, which are identified below: ____________________ daytime ____________________ evening ____________________ Check No. _________________ Date _________________________ Amount $ ________________________ Check No. _________________ Date _________________________ Amount $ ________________________ Check No. _________________ Date _________________________ Amount $ ________________________ Check No. _________________ Date _________________________ Amount $ ________________________ Check No. _________________ Date _________________________ Amount $ ________________________ 6. That the above checks have been lost misplaced missing destroyed stolen other (describe) ______________________________________________________________________________________ 7. By this affidavit, I am requesting that Clerk of the Circuit Court of Cook County, place stop payment(s) on the check(s) listed above and issue a replacement check. I further understand that under circumstances should I present any of the checks listed for payment if they should come into my possession after the filing of this affidavit. 8. I further understand that by presentation of this affidavit and the issuance of a replacement check by the Clerk of the Circuit Court of Cook County, 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 any of the checks listed above to any bank, financial institution, currency exchange or other third party, _________________________________________ Signature of Client Signed and sworn to before me on this ___________ day of ___________________________, ________ ___________________________________________ Notary Public (THIS FORM MAY BE FAXED TO 312-345-4146 OR MAILED TO 28 N. CLARK, ROOM 200, CHICAGO, IL 60602) FORM MUST BE NOTARIZED DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS