Declaration Of Loss Official Check Form - California Page 2
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1
2DECLARATION OF LOSS
OFFICIAL CHECK
10. I understand that if the bank pays me after this claim becomes enforceable, the bank will be
relieved of liability on the check. If the bank has paid me and a holder in due course presents
the check for payment, I agree to do the following:
a. If the bank pays the check, I must refund to the bank the amount of the check within
10 days from the date written demand from the bank is sent to the last known
address shown on the bank’s records.
b. If the bank does not pay the check, I must pay the amount of the check to the holder
in due course.
11. If I do not refund to the bank the amount of the check upon request, I understand that the
bank may enforce its rights in a court of law. I agree that in any court action to enforce this
Declaration of Loss, whether I commence the action or the bank commences the action, the
prevailing party will be entitled to reasonable court costs, including attorney’s fees.
12. I agree to defend, indemnify and hold the bank harmless from any expenses, loss or damage
incurred as a result of the bank releasing the proceeds of the above described check or
relying on other instruction or information provided by me, including any claim by any person,
organization or corporation arising from any transfer, pledge, negotiation or assertion of any
interest in the above described check. I also agree to indemnify and hold the bank harmless
for any and all loss or damage, including expenses and costs, including reasonable attorneys
fees, on account of the bank’s refusal for payment of such item to any other claimant thereon.
13. I understand that the bank will rely upon the statements contained in this Declaration of Loss.
Executed this _______ day of __________________, 20______.
____________________________________________________
Print Name
____________________________________________________
Signature
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