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Nebraska State Court Form AFFIDAVIT OF LOST CHECK CC 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):
