IN THE CIRCUIT COURT OF THE SIXTEENTH JUDICIAL CIRCUIT KANE COUNTY, ILLINOIS Case No. Plaintiff/Petitioner Defendant/Respondent S MISSING OR OUTSTANDING CHECK I, , being first duly sworn upon (Name and Address of person making affidavit) oath depose and state the following: 1. A check was issued by DEBORAH SEYLLER, Clerk of the 16th Judicial Circuit Court of Kane County, Illinois or the Illinois State Disbursement Unit which is identified as follows: Check No. Date: Drawn on: Amount: Bank under Account No. 2. That the above described check 3. That the above described check is has not been received by me. has lost misplaced missing destroyed outstanding . other (describe) 4. By signing this affidavit, I am requesting that DEBORAH SEYLLER, Clerk of the 16th Judicial Circuit Court of Kane County, Illinois or the Illinois State Disbursement Unit to place a stop payment on the above described check and to issue a replacement check. I understand that under no circumstances should I present this check for payment if it should come into my possession after filing this affidavit. 5. I further understand, that by filing this affidavit and the issuance of a replacement check by DEBORAH SEYLLER, Clerk of the 16th Judicial Circuit Court of Kane County, Illinois, or 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 the above described check at any bank, financial institution, currency exchange or other third party. State of County of Signature of Affiant SUBSCRIBED AND SWORN TO before me this (Date) Address: City, State, Zip: NOTARY PUBLIC Phone No: SS No: P1-MISC-053 (04/09) [identify copy] American LegalNet, Inc. www.FormsWorkflow.com