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Check Handling Information APPENDIX I and Procedures 7/14 Page 13

Lost Check Report All questions must be answered

Date of Report ________________________ Payee____________________________________________ Address of Payee_______________________________________________________________________ ______ ____________________________________________________________________________________________

Phone #: Home ______________________ Work _________________________ Cell ______________________

Check Number _____________ Amount _______________ Date of Check______________ Did you receive the check? Yes No If yes, where did the loss occur? Home Work Auto Other __________________________________ Are any other items, such as identification, lost/missing? Yes

No

If so, what type? ______________________________________________________________________________ I agree by signing this report to cooperate with the Department of Social Services and any law enforcement agencies in the investigation and/or prosecution of any person(s) who may be responsible. (This information will be supplied to the financial institution who negotiated the check and law enforcement agencies to assist in prosecution.) Additionally, I state that this information is true and correct, and understand that making a false sworn statement is subject to federal and/or state statutes and may be punishable by fines and/or imprisonment.

Please sign your name on the following lines:

__________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________ _________________________________________ __________________________________________ __________________________________________ __________________________________________ __________________________________________