Affidavit For Lost Or Stolen Cashier's Check
Please complete the form below:
*Indicates a required field.
MEMBER INFORMATION
Member Account Number
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First Name
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Last Name
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Social Security Number
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Phone Number
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Address
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Address Line 2
City
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State
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Zip Code
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Email Address
Provide email address if you would like confirmation of submission.
CHECK INFORMATION
Check Number
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Check Date
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Amount
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Payable To The Order Of
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Purpose For Which Check Was Drawn
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Circumstances Of Loss Or Theft
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I/WE,
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(Enter First & Last Name), the undersigned, do depose and say that I am the only lawful owner of the above described check issued by Financial Assurance Federal Credit Union. I further swear that I have not in any way disposed of said item nor of my interest in the same; that said item has been lost or stolen and I am unable to produce the same.
I, therefore, request Financial Assurance Federal Credit Union to stop payment on the said instrument and to issue a new one in its place.
In consideration of the issuance of the duplicate check, I agree to hold Financial Assurance Federal Credit Union harmless of and from any loss, damages, claim and expense, which may be sustained or incurred by Financial Assurance Federal Credit Union in respect to the hereinabove described original check and its duplicate requested to be issued. This agreement shall be binding upon my heirs, executors, administrators and assigns.
In addition, I agree to deliver to Financial Assurance Federal Credit Union, the original instrument for cancellation if same should be found.
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Yes, I agree to and have read the above paragraph stating the terms and conditions of the Lost/Stolen Cashiers Check Affidavit.
ELECTRONIC FORM SECURITY DISCLOSURES
By selecting this field I am verifying the following:
1)The above information entered has indeed been entered by myself, the account owner or joint owner, and that submission of this form gives full authority to conduct the above requested action.
2)I understand that I do have the option or right to submit this form in the paper form, which is available either through our website at www.fafcuny.org and/or upon request by contacting the credit union.
3)I understand that I exercise the right to withdraw consent to have records provided electronically, including any conditions, consequences, or fees associated with doing so. To withdraw consent I must submit written documentation with my request and verify receipt of its retrieval.
4) By entering my first and last name next to the Electronic Signature field, this stands as the equivalent of a handwritten signature. Therefore, by entering fraudulent or false information, you are committing forgery and subject to the same applicable laws and penal action.
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Yes, I agree to and have read the above paragraph stating the terms and conditions of submitting a form electronically.
Electronic Signature (please print your first and last name)
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Today's Date
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