Cash Bail - Stop Payment Affidavit Form printable pdf download

NYC DEPARTMENT OF FINANCE

TREASURY DIVISION

C A S H

S T O P PAY M E N T A F F I DAV I T

B A I L

Department of Finance

Mail to: NYC Department of Finance, Treasury/Court Assets, 66 John Street, 12th Floor, New York, NY 10038

Instructions: Use this affidavit to request a stop payment on a check and a replacement check. This form must be completed by the person

that paid the Cash Bail (i.e. the Surety). Complete, notarize, and submit this form along with a valid government picture ID such as a driver’s

license, passport, or benefit card. If you do not have a valid government issued ID you will need to provide copies of two (2) forms of ID to

verify your identity. At least one ID must have a photo and signature such as an employment or school ID. Other types of acceptable identifi-

cation include a utility bill issued within 60 days, an ATM/Bank Card, or Social Security Card. For additional information visit our Cash Bail/Court

& Trust Section at

or contact us at 212-908-7619 or visit us at

nyc.gov/contactcashbail

S E C T I O N I - A P P L I C A N T I N F O R M A T I O N

Indicate the name and address of the payee requesting a stop payment.

1. Name of Surety/Payee: ______________________________________

___________________________________________

PRINT LAST NAME OF SURETY

PRINT FIRST NAME OF SURETY

2. Current Address:_________________________________________________________________ Apt. #: _________________

NUMBER AND STREET

City: ________________________________________________________ State: ___________ Zip Code: ________________

3. Phone Number: _______________________________

4. Email Address: ________________________________________

S E C T I O N I I - B A I L I N F O R M A T I O N

1. Print the name of the defendant: __________________________________

_______________________________________

LAST NAME

FIRST NAME

2. Print the Docket, Indictment and/or Treasury Receipt Numbers below:

______________________________

________________________________

DOCKET

INDICTMENT

TREASURY RECEIPT

S E C T I O N I I I - C E R T I F I C A T I O N

I certify that I am the above named payee and I did not receive the check indicated and request the Department of Finance to stop payment

on said check and issue a new check. I hereby acknowledge that the information provided is true and correct to the best of my knowledge.

_________________________________________________

Signature of Surety

Sworn to before me

Notary

on __________________________________, 20________

Affix

Stamp

Here

_________________________________________________

Notary Public/Commissioner of Deeds

F O R O F F I C I A L U S E O N L Y

Amount of Check: $ _____________ Check Number:______________

Approximate Date Check Was Mailed: ____________

Check “mailed to” Address: ________________________________________________________________________________

_________________________________________________

_______________________________________________

Court Assets Member Approval and Date

Supervisor Approval and Date

Visit Finance at nyc.gov/finance

StopPay

12.11.2015

Cash Bail - Stop Payment Affidavit Form

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