IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI ( ) AT KANSAS CITY ( ) AT INDEPENDENCE ______________________________ VS. ______________________________ NO. ______________________ LOST CHECK AFFIDAVIT STATE OF MISSOURI ) ) SS. COUNTY OF JACKSON ) The undersigned, of lawful age, being first duly sworn, alleges and states as follows: 1. 2. Name: ___________________________________________________________ That I reside at _____________________________________________________ ____________________________________________________________ 3. ( ) I failed to receive: ( ) I lost: Circuit Court Check No. ___________________ in the amount of $_____________, dated ____________________ payable to me and that after a search for same, I have been unable to locate said check. That this affidavit is made for the purpose of having a substitute check issued to me in the amount of $_________________ to replace the check referred to in paragraph 2 hereof and the Court Administrator is hereby authorized to use this affidavit for any purpose whatsoever in regards to said lost and/or substitute check. That if I locate the check referred to in paragraph 2 hereof, I will immediately advise the Court Administrator and deliver said check to this office. That if the check referred to in paragraph 2 hereof and the substitute check are both cashed, the Court Administrator is authorized to pursue legal recourse. 4. 5. 6. ________________________________________ Signature Subscribed and sworn before me on ____________________________. ________________________________________ NOTARY PUBLIC My Commission Expires: __________________________ CIRCT 1030 Revised: 8/99 American LegalNet, Inc. www.FormsWorkflow.com