STATE DISBURSEMENT UNIT
Customer Service: (877) 225-7077
AFFIDAVIT OF LOST, MISSING, OR STOLEN CHECK
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:
Check Issue Date:
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_____,
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