I, ______________________________, (the Assignor”) residing or doing business at
_____________________________________________ (Street, City, State, and Zip Code), do
hereby assign to ______________________________ (the Assignee”), residing or doing
business at _____________________________________________ (Street, City, State, and Zip
Code), the consideration held by the Brevard County Clerk of the Circuit Court (the “Clerk”) in
the amount of $_______________, originally issued to me via check number _______________
dated ____________________, 20_____, that has been lost, stolen, or misplaced (the
“Consideration”) by me.
I hereby agree to hold harmless and indemnify the Clerk from any and all future liability
regarding the Consideration upon the Clerk’s remittance of the Consideration to the
Assignee, contingent upon the filing of a Lost Check Affidavit with the Clerk. I understand that
upon execution of this Assignment of Interest, any and all interest I have in the specified
Consideration immediately transfers to the Assignee.
Further, I affirm that should I come into possession of the original check which I have
indicated as lost, stolen, or misplaced, that I will return the same to the Clerk in care of the
Clerk’s Finance Department at P.O. Box 999, Titusville, Florida 32781-0999. I agree that I shall
not cash or otherwise attempt to deposit the lost, stolen, or misplaced check and understand that
in the event I do cash or otherwise deposit the check, that the Clerk may refer the matter to the
State Attorney for the 18
Judicial Circuit for investigation and that I may be subject to
prosecution under the laws of the State of Florida.
Signature of Assignor
STATE OF ____________________
COUNTY OF ____________________
The foregoing instrument was acknowledged before me this _____ day of
____________________, 20_____, by ______________________________, who is
personally known or who produced ______________________________ as identification.
Signature of Notary Public/Deputy Clerk
Printed Name of Notary Public/Deputy
Return the or
iginal to:
revard County Clerk of the Circuit Court
Finance Department
P.O. Box 999
Titusville, Florida 32781-0999
Telephone: (321) 637-2002
Facsimile: (321) 264-5227
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