Lost Cheque Affidavit - Family Responsibility Office

Affidavit for a Lost Cheque

Ministry of Community and Social Services

Family Responsibility Office PO Box 200 Stn A

Oshawa ON L1H

I, ______ of ______ in the County / District / Regional Municipality of ______ do hereby swear and state as follows:

1. I declare that I ______ did not receive, or received and thereafter lost, cheque number ______ dated ______, in the amount of ______ $ ______ reportedly issued by the Family Responsibility Office drawn on the ROYAL BANK OF CANADA, Toronto, Ontario, with respect to Family Responsibility Office Case Number: ______

2. I additionally declare that I have not been paid this sum through any alternative means.

3. Should a replacement cheque be issued in my name, I undertake not to negotiate, endorse, or assign the original cheque if it comes into my hands, and to promptly return it to the Ministry of Community and Social Services, or the relevant successor entity.

4. I further undertake that if the Minister of Finance incurs any loss arising from the issuance of a replacement cheque, I will indemnify the Minister for all costs, damages, interest, and expenses resulting from any claim brought by me or my assignees, endorsees, or transferees on either the original or the replacement cheque, and I authorize the Minister of Finance to deduct the value of any such loss from any future payments owing to me.

5. To the best of my knowledge, information, and belief, the original cheque has not been cashed and has not been deposited into any account held by me.