Nebraska State Court Form AFFIDAVIT OF LOST CHECK CC 23:11 Page 1 of 1 AFFIDAVIT OF LOST CHECK CC 23:11 New IN THE COUNTY COURT OF COUNTY, NEBRASKA Plaintiff vs. Defendant Case AFFIDAVIT OF LOST CHECK I, , state that heck umber: in the amount of $, ssued on in association with case number: has either been lost or misplaced. I am submitting this affidavit requesting that the lerk of the ounty ourt of County, Nebraska issue a new check replacing the previously mentioned check. I will owe the lerk of the ourt a penalty of $if the original check is paid by the bank. Date Signature(Do not sign until a notary is present) Name Street Address/P.O. Box Bar Number and Firm Name (attorneys only) City/State/ZIP Code Phone E-mail Address State of ) ) ss. County of ) The foregoing instrument was acknowledged before me by , this Name of person certifying above day of , . Day Month Year Notary Public (signature of person taking acknowledgment) My commission expires: (title or rank) (serial number, if any) American LegalNet, Inc. www.FormsWorkFlow.com