P.O. Box 5921

Carol Stream, IL 60197-5921

Customer Service: (877) 225-7077




I, ____________________________________________, being first duly sworn upon oath, depose and state the following:


1.        A check was issued by the ILLINOIS STATE DISBURSEMENT UNIT, which is identified as follows:


Issuing County:

Docket Number:

Check Number:

Check Issue Date:


Payable To:

2.  That the above-described check                     HAS      HAS NOT                   been received by me.


3.  That the above-described check has been

                LOST                      STOLEN                                MISSING                               DESTROYED


4.     That by this affidavit I am requesting that the ILLINOIS STATE DISBURSEMENT UNIT place a STOP PAYMENT on the above-described check and to reissue a replacement check.  I further understand that under no circumstances should I present the above described check for payment if it should come into my possession after the filing of this affidavit.


5.    I, _________________________________________, further understand that by presentation of this affidavit and the issuance of a replacement check by 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 or present the above described check to any bank, financial institution, currency exchange, or any other third party.


                ____________________________                                               Subscribed and sworn to before me this

                                Signature of Affiant                                           

_______day of_____________, 20_____,



                        Notary Public


Original notarized form MUST be mailed into the ILSDU.  We are unable to accept faxed copies.  This will delay the processing of your request.


The information required to submit the above affidavit of a potential lost, missing or stolen check can be obtained by calling Illinois State Disbursement Unit Customer Service at (877) 225-7077.  After you complete the form mail it to the Illinois State Disbursement Unit at the above address