Claim to Lost, Stolen, or Destroyed
Cashier's Check, Teller's Check or Certified Check

I, ________________________________________, (print or type name of claimant) hereby assert a claim to the following described cashier's check, teller's check or certified check:

                  Remitter: ____________________

                  Payee: ____________________

                  Date: ____________________

                  Amount: ____________________

                  Check number: ____________________

                  Account number: ____________________

(a copy of the remitter's copy may be attached)

and request payment of the amount of the check. My Declaration of Loss is attached hereto. I understand that the claim has no legal effect until it is enforceable. A claim becomes enforceable at the LATER of
  1. the time the claim is asserted; or
  2. the 90th day following the date of the check, in the case of a cashier's check or teller's check or the 90th day following the date of acceptance in the case of a certified check.

I further understand that my claim may be unenforceable if the Declaration of Loss fails to meet the requirements of Section 3-312 of the Uniform Commercial Code or if it fails to reach the bank at a time and in a manner which affords the bank reasonable time to act on it before the check is paid.

I agree to provide reasonable identification if so requested by the bank.

___________________________________________
Signature of claimant

Date: ____________________________________

Declaration of Loss

I, ____________________________________________________, was the drawer/payee (circle one of these choices if the item was a certified check) of the above-described certified check OR the remitter/payee of the above-described cashier's check or teller's check (circle one of these choices if item was a cashier's check or teller's check). I lost possession of the check. The loss of possession was NOT the result of a transfer of the check or a lawful seizure and I cannot obtain possession of the check because

the check was destroyed;
the check is in the wrongful possession of an unknown person;
the whereabouts of the check cannot be determined; or
the check is in the wrongful possession of a person that cannot be found or is not amenable to service of process.

The following is a brief description of the circumstances surrounding the loss, destruction, or theft of the cashier's check, teller's check or certified check:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

The statements made herein are made under penalty of perjury and I warrant them to be true and correct.

I understand that if this claim is paid and the check is later presented for payment by a person having the rights of a holder in due course, I am obliged to either refund the payment to the bank if the check is paid or pay the amount of the check to the person having rights of a holder in due course if the check is dishonored.

Dated this ___________ day of _____________________, ___________.


_________________________________________________________
Signature of Claimant