LOST CHECK INFORMATION
NAME OF PAYEE
CHECK NUMBER
DATE OF CHECK
AMOUNT OF CHECK
STATE OF FLORIDA
COUNTY OF BREVARD
BEFORE ME this day personally appeared _________________________________________________, who, being
duly sworn, deposes and says that to this date, he/she has not received the above referenced check. If said check is
received after the signing of this affidavit, it will be mailed immediately to the Clerk's office.
AFFIANT SIGNATURE
AFFIANT STREET ADDRESS
PHONE NUMBER
SWORN to and SUBSCRIBED before me this __________ day of ________________________ 20_____ .
NOTARY PUBLIC/DEPUTY CLERK
STOP PAYMENT ISSUED TO BOOKKEEPING _________________ CHECK CASHED____________________
REPLACEMENT CHECK NUMBER __________________________
REPLACEMENT CHECK DATE _____________________________
LAW 138
Rev. 09-2012
IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT,
BREVARD COUNTY, FLORIDA
IN THE COUNTY COURT, BREVARD COUNTY, FLORIDA
DIVISION
CASE NUMBER
CL OCK IN
DEFENDANT
PLAINTIFF
LOST CHE CK AFFIDAVIT
BAR CODE LABEL
PARTICIPANT ID#
AFFIANT ADDRESS/APT #.
CITY/STATE/ZIP
