(please print all information)
I, _
(first) (middle) (last)
1. That the address of the above is: ___________________________________________________________________
(street, apt #, city, state, zip code)
County of ________________________________ . Mailing address (if not same as above address) ___________
2. That check no. _____________, dated ____________, drawn by the Palm
Beach County Tax Collector on Wells Fargo Bank N.A.,
in the amount of $ _____________was issued payable to the order of
and I make application for a duplicate check to replace said check which has been lost or destroy
3. That the check (was) (was not) endorsed. If endorsed, state exactly
the matter of all endorsements appearing thereon:
4. That, except as stated above, the whereabouts of said check is unknown to me.
5. In consideration of the Tax Collector’s reliance upon the foregoing representations and certifications and in further consid
eration of
the Tax Collectors compliance with the foregoing request, the undersigned hereby agrees to indemnify and hold the Tax Collector
harmless from and against any and all claims, demand, losses, damages, actions, including expenses, costs and reasonable attorney’s
fees which the Tax Collector at any time may sustain or incur by reason of the Tax Collector’s reliance upon the foregoing
representations and warranties and compliance with the foregoing request of the undersigned.
The undersigned understands that the liability of the undersigned to the
Tax Collector, including without limitation, the payment to the
Tax Collector of a sum of money equal to the original check or the assertion is made. The undersigned hereby agrees to deliver to the
Tax Collector for cancellation the original Tax Collector’s check if the same shall ever be found.
On this day before me, an officer duly qualified to take acknowledgm
ents, personally appeared
to me known to be the person described in and who executed the foregoing instrument and acknowledged before me that (he/she)
executed the same.
WITNESS my hand and official seal in the County of and State of , last aforesaid this
day of
, .
My commission expires:
PBCTC FORM #148 (05/08)