Form Ccsd 0693 - Affidavit Form For Lost, Missing Or Stolen
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1Affidavit of Lost, Missing or Stolen Check
(12/11/06) CCSD 0693
(This form replaces CCG 0693)
IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
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STATE OF ILLINOIS
ss:
COUNTY OF COOK
AFFIDAVIT OF LOST, MISSING OR STOLEN CHECK
(COOK COUNTY CHECKS)
____________________________________________
___________________
CASE NUMBER(S)
SOCIAL SECURITY NO.
_____________________________________________
I,
, being first duly sworn on oath, state the following:
(Name of person making affidavit)
1. I am the Petitioner in the above mentioned case number(s) filed in the Circuit Court of Cook County.
______________________________________________________________________________________
2. I reside at
.
____________________
____________________
____________________
3. My telephone number
daytime
evening
4. I receive child support through the State Disbursement Unit pursuant to an Order for Support.
5. Checks were issued by DOROTHY BROWN, Clerk of the Circuit Court of Cook County, which are identified below:
_________________
_________________________
________________________
Check No.
Date
Amount $
_________________
_________________________
________________________
Check No.
Date
Amount $
_________________
_________________________
________________________
Check No.
Date
Amount $
_________________
_________________________
________________________
Check No.
Date
Amount $
_________________
_________________________
________________________
Check No.
Date
Amount $
6. That the above checks have been
lost
misplaced
missing
destroyed
stolen
other (describe)
______________________________________________________________________________________
7. By this affidavit, I am requesting that Clerk of the Circuit Court of Cook County, place stop payment(s) on the check(s)
listed above and issue a replacement check. I further understand that under circumstances should I present any of the
checks listed for payment if they should come into my possession after the filing of this affidavit.
8. I further understand that by presentation of this affidavit and the issuance of a replacement check by the Clerk of the
Circuit Court of Cook County, 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 any of the checks listed above to any bank, financial institution, currency exchange or
other third party,
_________________________________________
Signature of Client
___________
___________________________
________
Signed and sworn to before me on this
day of
,
___________________________________________
Notary Public
(THIS FORM MAY BE FAXED TO 312-345-4146 OR MAILED TO 28 N. CLARK,
ROOM 200, CHICAGO, IL 60602)
FORM MUST BE NOTARIZED
DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS
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