Declaration of Lost or Destroyed University of California, Davis - Check

Payee First Name

Payee Last Name

Employee ID/Student ID #

Email Address

Check #

Amount

Check Date

Reason for replacement or request

Check was lost

Check was destroyed

Action Requested

Stop Payment - Reissue

Stop Payment - No Reissue

Please designate where the check should be sent below

I have been informed that the above referenced check, drawn by The Regents of The University of California against its account maintained with Wells Fargo Bank – Davis office, was issued.

The facts of such (destruction/loss) insofar as known to me are as follows:

If the original check is eventually found, I agree that I will not negotiate, deposit or cash said check, but will immediately deliver it for cancellation to the Accounts Payable office, located at 1441 Research Park Dr., Rm 170, Davis, California 95618.

I further agree that for and in consideration of the re-issuance to me of a check in lieu of the check originally issued and subsequently lost or destroyed, I will indemnify and hold harmless The Regents of The University of California against loss, damage, expense or any other liability which may be suffered by said The Regents, either directly or indirectly, by reason of the issuance of said duplicate check or by the original instrument still remaining outstanding.

I hereby request that The Regents issue a new check to me in lieu of the above referenced check that was lost/destroyed.

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