Remitter Name: First MI Last Suffix
Account No. Date of Check (MM/DD/YY) Check Serial No. (Required) Amount
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Payee’s Name: First MI Last Suffix
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Signature
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Date (MM/DD/YY) Daytime Telephone No.
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
Declaration of Loss (Claim to Lost, Stolen, or Destroyed Cashier’s Check)
To submit a Declaration of Loss for a Navy Federal Credit Union-issued/signed check, please complete and sign the form below.
You can send a scanned copy via secure message on Navy Federal Online Banking, or mail it to Navy Federal Credit Union,
P.O. Box 3000, Merrifield, VA 22119-3000, Attn: Funds Disbursement @ Funds Services Branch.
Under the penalty of perjury, I, remitter payee, state that:
• I have lost possession of this check;
• the loss of possession of the above-referenced check was not the result of a transfer by me or a lawful seizure of the check; and
• I
cannot reasonably obtain possession of the check because (check one):
the check was destroyed.
the check is lost.
the check was stolen by a person unknown who cannot be found or who will not accept service of process.
Deposit Instructions
Please indicate how you would prefer the funds be made available:
Deposit to NFCU account
Send new cashier’s check to the following:
Other:
Indemnity Agreement Regarding a Lost, Stolen, or Destroyed Check
I understand that if this claim is honored, the funds will be deposited into the account from which the check was originally purchased
to process a replacement check. If the account is closed, the account may be reopened to fulfill this request and then will be reclosed.
I further understand that if this claim is paid and the check is presented for payment within 90 days of the check issuance date,
Navy Federal Credit Union is obliged to honor the check and I am obliged to refund the payment to Navy Federal.
If the check is presented for payment by a holder in due course after 90 days from the check issuance date, I am obliged to either
refund the payment to Navy Federal if the check is honored or pay the amount of the check to the person having rights of a holder in
due course if the check is dishonored.
In any of these circumstances, I agree to reimburse Navy Federal for all expenses or costs it incurs as a result of not honoring the check
or as a result of my lack of prompt reimbursement of the payment to Navy Federal if the check is honored.
© 2020 Navy Federal NFCU 170A (8-20)
*170A*
