AFFIDAVIT
STATE OF UTAH
COUNTY OF UTAH
I, _______________________________________ , whose UV ID is and whose
present address is ___________________________ being first duly sworn, disposes and
says that he/she requests a duplicate warrant be issued to him/her to replace check # ___________
dated ________ in the amount of __________________ . That said check has been lost and
after making a thorough search, he/she has been unable to find same check. That said check was not
endorsed by him/her. That he/she hereby promises to hold UTAH VALLEY UNIVERSITY harmless if any
loss occurs through the issuance to him/her of the duplicated check. That he/she will repay to UTAH
VALLEY UNIVERSITY any sum which may be paid by UTAH VALLEY UNIVERSITY on the account of said lost
check.
Signature of Student
Sworn and subscribed before me this_ __ day of ________ , 20_ _____at__
__________
Notary Public
Notary Address
Seal
City, State, Zip
Commission Expires: ________________________________
For Office Use Only:
Initial and Date Each Entry
Check Cashed Y or N
If Y, enter date.
If N, Place Stop Payment
On Wells Fargo/Date
VOID Check in
Banner/FAACHKS
Cancel Check on Student
Account/TSAAREV
Replacement Check
Issued/TSAAREV
