FORM MUST BE FILLED OUT IN ITS ENTIRETY AND NOTARIZED, FAILURE TO DO SO WILL CAUSE THE AFFIDAVIT NOT TO BE PROCESSED. THERE IS AN $15.00 CHARGE FOR EACH CHECK THAT YOU ARE REQUESTING A STOP PAYMENT ON. A CHECK OR MONEY ORDER MUST ACCOMPANY THIS REQUEST. AFFIDAVIT claiming lost, destroyed, undelivered, or stolen Monroe County Friend of the Court’s office check __________________________________________________________________________________ Check# Date of Check Amount ___________________________________________________________________________________ Account# Daytime Phone Number Payer’s Name __________________________________________________________________________________ Payee’s Name Payee’s SS# Payer’s SS#(if known) __________________________________________________________________________________ Street Address City State Zip Code I, ___________________________________being duly sworn, depose and say: ( print or type name of payee) That I am the payee named in the above Monroe County Friend of the Court check issued by S. Joseph Hudson III Monroe County Monroe County Friend of the Court, and said check has not been assigned, transferred or set over by me to any person whomsoever, and I am the true, lawful and only owner thereof. Further, that I have not received directly or indirectly the money nor any portion of the money directed to be paid to me in the check. Whereas, on the faith of the foregoing, I request Monroe County Friend of the Court issued a new check to replace the above check. Further, I agree that should the lost/destroyed/undelivered/stolen Monroe County Friend of the Court’s check be found or come into my hands, I will promptly deliver or cause the same to be promptly delivered to the Monroe County Friend of the Court to be canceled. Further, if any of the statements contained in this affidavit are false or misleading, I acknowledge that the Monroe County Friend of the Court may demand immediate reimbursement for any funds expended in reliance on the truth of the statements in this affidavit. Further, if any of the false or misleading statements were made with an intent to defraud the Monroe County Friend of the Court, I acknowledge that the Monroe County Friend of the Court may request that such an act be prosecuted to the full extent of the laws of this state. X_________________________________ (payee on check-sign in ink) Subscribed and sworn to before me, this_________day of______________________. 19_________. Notary Public in and for the County of ____________________, State of _____________________. __________________________________ Notary Public My Commission Expires:____________________ Please sign and return this form to Monroe County Monroe County Friend of the Court, Monroe, MI 48161 American LegalNet, Inc. www.FormsWorkflow.com