Lost Check Affidavit (Form 510) - Galveston County printable pdf download

Lost Check Affidavit (Form 510) - Galveston County

LOST CHECK AFFIDAVIT (FORM 510)

THE STATE OF TEXAS

COUNTY OF GALVESTON

I, _______________________, being first duly sworn, do depose and say that I am the

entity named as the payee of the check numbered __________________, drawn by the Treasurer

of the County of Galveston on _______________ for the sum of $___________.

Being still sworn, I further say that the above-described check has not been received or

negotiated by me. The above-described check has been____________________(

lost, stolen,

), and, by this affidavit, I am requesting that the County of Galveston place a stop

destroyed, etc.

payment on the above-described check, and issue a replacement check.

I understand that under no circumstances should I present the above-described check for

payment if it should come into my possession after the filing of this affidavit, and I hereby

indemnify and hold harmless the County of Galveston from any liability, loss, expense, or

damage which may occur as a result of the issuance of the original check and/or the replacement

check.

Affiant’s Signature __________________________________

Sworn to and subscribed before me this _______ day of __________________,

20______.

__________________________

My Commission expires

Notary Public in and for

___________________

__________________________

County, Texas.

Return ORIGINAL NOTARIZED FORM to:

For questions, contact:

Galveston County Treasurer’s Office

Marcie Bailey

Attn: Marcie Bailey

(409) 770-5387

722 Moody 4

Floor

Marcie.Bailey@co.galveston.tx.us

Galveston, Tx 77550

Lost Check Affidavit (Form 510) - Galveston County