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


1.        A check (s) was issued by the ILLINOIS STATE DISBURSEMENT UNIT  , which is identified as follows:
Affidavit may only be used for up to two checks per docket number.


Issuing County:

Docket Number:

Check Number:   
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 (s) for payment if it should come into my possession after the filing of this


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(s) 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



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.