STATE DISBURSEMENT UNIT
Customer Service: (877) 225-7077
AFFIDAVIT OF LOST, MISSING, OR STOLEN CHECK
_________________________________________________________, being first duly sworn upon oath,
state the following:
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.
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
_________________________________________, 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_____,
Original notarized form MUST be mailed into the ILSDU.Faxed copies will not be accepted.
The information required to
submit the above affidavit of a potential lost, missing or stolen check can be
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.