Form F399 - Affidavit Concerning Lost Check Page 2
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4NYCERS USE ONLY
F399
Mail completed form to:
30-30 47th Avenue, 10th Fl
Long Island City, NY 11101
Member Number
Last 4 Digits of SSN
Pension Number
The address below is a new address to which I want the replacement check and all future checks mailed.
In Care of (if Applicable)
Address
Apt. Number
State
Zip Code
City
Signature of Member
Date
Pursuant to The Penal Code of the State of New York, offering a document containing false statements or false information
constitutes a felony punishable by a maximum of 4 years imprisonment. All documents suspected of containing false statements
will be referred to The New York City Department of Investigation for investigation.
This form must be acknowledged before a Notary Public or Commissioner of Deeds
State of
County of
On this
day of
2 0
, personally appeared
before me the above named,
, to me known, and known to
me to be the individual described in and who executed the foregoing instrument, and he or she acknowledged to me that he or she
executed the same, and that the statements contained therein are true.
If you have an official seal, affix it
Signature of Notary Public or
Commissioner of Deeds
Official Title
Expiration Date of Commission
THIS AREA FOR NYCERS USE ONLY
[MM/DD/YYYY]
[MM/DD/YYYY]
/
/
/
/
Month of
LCA sent to C.O.
[MM/DD/YYYY]
[MM/DD/YYYY]
Amount $
Stop Payment on
/
/
Paid
/
/
MICR #
Serial # or
/
-
R11/17
Page 2 of 4
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