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GOVERNMENT OF

THE VIRGIN ISLANDS OF THE UNITED STATES

CHARLOTTE AMALIE, ST. THOMAS, V.I. 00801

-----0-----

Department of Finance

AFFIDAVIT OF LOST CHECK

-----AGREEMENT OF INDEMNITY

Whereas, the Commissioner of Finance of the Virgin Islands has caused to be issued and delivered to me

a certain check No. _____________dated the ____ day of _______________, 20_____ in the sum of $____________

drawn on the

Firstbank of the Virgin Islands.

(Name of Bank)

Whereas, the undersigned has represented to the Commissioner of Finance of the Virgin Islands and now

declares that said check has been mislaid, lost, destroyed, not received or bears a signature that is either

unacceptable to the bank or not legible and has therefore applied to said Commissioner to issue a replacement

checker check which said Commissioner has consented to do (after a 60 day waiting period) upon receiving the

indemnity hereinafter contained:

Now, therefore, the said

__________________________________________ doth hereby agree

(Name of Payee)

to save harmless and indemnify the Government of the Virgin Islands from and against all claims and demands in

respect to the said check; and from against all damages, losses, cost, charges and expense which the

Government may sustain, incur or be liable for in consequence of it having issued a second check in lieu of the

one above described. And the undersigned further agrees to return said check to the Commissioner of Finance

forthwith if same shall be found.

Name (print):__________________________________________

Year:________________________________________________

Signature:_____________________________________________

SSN/EIN:_____________________________________________

Spouse Name (print):_______________________________________

SSN (Spouse):_________________________________________

(Mandatory if taxpayer filed joint return.)

Spouse Signature:____________________________________________ Mailing Address:_______________________________________

(Mandatory if taxpayer filed joint return.)

_______________________________________

Date:_____________________________________

_______________________________________

Telephone No:_________________________________________

Subscribed and sworn before me this:

_______day of ______________________20_____

__________________________________________

Notary Public

Affidavit Of Lost Check Agreement Of Indemnity Form - Government Of The Virgin Islands