Nebraska State Court Form

AFFIDAVIT OF LOST CHECKCC 23:11 Rev. 05/2020

Page 1 of 1 AFFIDAVIT OF LOST CHECK CC 23:11 Rev. 05/2020

Case No. ____________________

AFFIDAVIT OF LOST CHECK

I, _____________________________________, state that check number: _________________ in the amount of $__________________, issued on _____________________ in association with case number: ______________________has either been lost or misplaced.

I am submitting this affidavit requesting that the clerk of the court of County, Nebraska issue a new check replacing the previously mentioned check.

I will be responsible for reimbursing the clerk of the court $_________ if the original check is paid by the bank.

Date:Signature (Do not sign until a notary is present)

Name Street Address/P.O. Box

Bar Number and Firm Name (attorneys only) City/State/ZIP Code

Phone Email Address

______________________________________ , Plaintiff,

vs.

______________________________________ , Defendant.

State of ) ) ss.

County of )

, This document was acknowledged before me by this day of , 20 .

Notary commission expires: Signature of Judge/Clerk of the Court/Notary Public

Title: Serial Number (if any):