Declaration Of Loss - Claim To Lost, Stolen Or Destroyed Cashier'S Check - Usc Credit Union
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1DECLARATION OF LOSS
(Claim to Lost, Stolen or Destroyed Cashier’s Check)
Name: __________________________________
Account #: ___________________
USC Credit Union is hereby directed to attempt to stop payment on the following check:
Check #: ____________________ Amount: ____________
Date Issued: ____________
Payee: _______________________________________________________________________
………………………………………………………………………………………………………
Under penalty of perjury, I declare that:
• I have lost possession of the check; and
• the loss of possession was not the result of a transfer by me or 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.
………………………………………………………………………………………………………
INDEMNITY AGREEMENT
I acknowledge that the item has not been delivered to any payee(s).
I understand that USC Credit Union may not be able to resist payment on the above described
item.
I understand that there is a sixty (60) day waiting period before I can receive a replacement or
refund for this item.
I understand that if this claim is paid and the check is later presented for payment, I am obliged
to refund the payment to USC Credit Union if the credit union is required to honor the check.
I understand that I must reimburse USC Credit Union for all expenses and costs it incurs as a
result of not honoring the check or a result of my lack of prompt reimbursement of the payment
to the credit union if the check is honored.
Signature: __________________________________
Date: __________________
Revised October 2015
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