Government of Ontario: Ministry of Community and Social Services

Family Responsibility Office
PO Box 200 Stn A
Oshawa ON L1H 0C5

Affidavit for a Lost Cheque

I,
of
make oath and say as follows:

1.



.
For the sum of

alleged to have been drawn by the Family Responsibility Office on the ROYAL BANK OF CANADA, Toronto, Ontario

2. I further certify that I have not received payment of such amount by any other means.

3. In the event of a duplicate cheque being issued made payable to me, I agree not to cash, endorse, or transfer the original cheque should it ever come into my possession, but to return the same to the said Ministry of Community and Social Services.

4. I further agree that should the Minister of Finance suffer any loss whatsoever by reason of the issue of a duplicate cheque, I shall indemnify him against all costs, damages, interest and expenses which he may bear or incur as a result of any claims being made by me or my assignees, endorsees or transferees where such claim is made on the original cheque or the duplicate cheque, and I hereby authorize the Minister of Finance to withhold the amount of such loss for any future payment due me by him.

5. According to the best of my knowledge, information and belief, this cheque has not been cashed nor has same been deposited to any of my accounts.






Instructions: Mail your completed form to: Family Responsibility Office    PO Box 200 Stn A, Oshawa  ON  L1H 0C5

***Please note:  Cheque number, cheque amount, date of cheque issuance, and case number can be obtained from the Family Responsibility Office to be included in the form prior to being witnessed.  Please contact the Family Responsibility Office at 416 326-1817 or 1 800 267-4330 for further details.