PLEASE ATTACH A COPY OF GOVERNMENT ISSUED IDENTIFICATION (i.e. Driver’s License)
I, , hereby claim check number in the amount
of $ referred to on the Clay County Clerk of Courts website or other sources. I certify
that I am the person to whom these funds are due, or that I represent the business entity to which these funds
belong.
Current Address:
This address must match the address on the
government issued identification attached
hereto for individuals or business
letterhead for business claims. This will be
the address that the check will be mailed.
If your name has changed, please call our office for assistance in providing documentation to support the
name change on the reissued check.
Current Phone Number Date of Birth
Tax Payer ID # (for businesses only)
Signature Date
State of
County of
Sworn to (or affirmed) before me this day of , 20 by
who has produced
as identification. (SEAL)
Signature Deputy Clerk/Notary Public Printed Name
