Declaration Of Loss Official Check Form - California

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I (including any and all of the undersigned, jointly and severally) declare under penalty of perjury,
under the laws of the State of California, that the following information is true and correct:
1. I am the ___________________________________(remitter or payee) for a official check
number ________________ dated _________________ in the amount of $______________
payable to ____________________________________.
2. I have lost possession of the check on or about _______________________________(date).
I did not willfully give the check to anyone. The check was not lawfully taken from me, for
example, in a court ordered seizure.
3. The check was:
(check one)
Lost (the location of the check is unknown)
4. I cannot reasonably obtain possession of the check because the check was destroyed, its
location cannot be determined, or it was stolen and it is now in the wrongful possession of an
unknown person or a person that cannot be found or is not amenable to service of process.
5. If the check was stolen I have
, have not
filed a police report. The police report, if
applicable, was filed on _______________ with the _________________ police department.
6. I request that you pay the amount of the check, when this claim becomes enforceable in the
form of:
(check one)
Credit my account number ________________________.
Issue a cashier’s check made payable to the undersigned.
7. I understand that this claim may not be immediately enforceable.
The claim will be
enforceable on the later of the following:
a. The date of this claim
b. Ninety(90) days from the date of the check.
8. I understand that the bank must have a reasonable time to respond to this claim before the
claim will be enforceable.
9. I understand that until this claim becomes enforceable, the bank may pay the person who is
entitled to enforce the check. If the bank pays the person who is entitled to enforce the
check, I understand that the bank will be relieved of liability to me and that I cannot enforce
this claim.


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