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NJ DCF Logo with reverse copy

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date:

Volume:

X

Forms

Chapter:

A

Forms

1-1-2011

Subchapter:

1

Forms

Issuance:

16.8

CP&P Form 16-8, Affidavit for Loss of Check

 

Click here to view, complete, and/or print CP&P Form 16-8, Affidavit for Loss of Check.

 

WHEN TO USE IT

 

CP&P Form 16-8, Affidavit for Loss of Check, is used whenever a check, written on the Local Office Bank Account (LOBA), is lost or stolen.

 

The Affidavit for Loss of Check is a notarized statement from the payee which includes:

 

      Payee's identity and residence;

 

      A description of the lost or stolen check; and

 

      Payee's promise to return the original check, and not attempt to cash it, if it is recovered.

 

HOW TO USE IT

 

The top portion of the form is completed by the Local Office Bank Account Clerk (Custodian), by hand, or using the template in the on-line Forms Manual.

 

The payee signs the Affidavit in the presence of a Notary.

 

The Notary signs and affixes his or her seal to the document, to notarize the Affidavit.

 

TIPS FOR COMPLETING THE FORM

 

The Local Office Bank Account Clerk (Custodian) completes the form as follows:

 

County of -- Enter the county in which the form is signed. If signing out of state, the Custodian leaves "County" blank and deletes New Jersey. (The Notary enters the appropriate State and County.)

 

SS# -- Enter the payee's Social Security number.

I,       , being duly sworn . . . . -- Enter the full name of the payee in the space provided after "I."

 

I reside at -- Enter the payee's full address.

 

Check # -- Enter the full number which corresponds to the lost or stolen check, issued from the Local Office Bank Account.

 

Dated -- Enter the date the lost or stolen check was issued.

 

For $ -- Enter the exact dollar amount of the lost or stolen check.

 

Payable to -- Enter the name of the payee, as it appeared on the lost or stolen check.

 

For -- Enter the purpose for which the money was to be used.

 

 …for the period From/To -- Enter the date on which the goods or service was to be rendered/expenditure made, or the period of time for which the Independent Living food or rent check, or the check for another service, was to cover.

 

The Notary completes the "Subscribed and Sworn" portion of the form.

 

The payee signs the form in the designated space in the presence of the Notary.

 

DISTRIBUTION

 

Signed Original        -           Local Office fiscal records file - the "LOBA File" maintained by the Local Office Bank Account Clerk (Custodian)

 

Signed Copy             -           Payee

 

Signed Copy             -           DCF Office of Accounting