Section Twelve A Affidavit Lost Check Form
Fidelis Care Provider Manual V20.0-12/9/19
12A
AFFIDAVIT OF LOST / STOLEN / DESTROYED CHECK
________________________________ deposes and says:
(Name of Payee’s Representative)
1. That the payee, _____________________, has not received Check No. __________, in the amount of
$___________, and that the check has been lost/destroyed/stolen on or about / / .
2. That the payee requests that Fidelis Care notify the bank to place a stop payment on Check No.
_________, and that Fidelis Care issue a duplicate check in lieu of such stopped check.
3. That neither the payee nor any person acting under orders, authority, or control of the payee has
attempted or will attempt to negotiate Check No. _______________.
4. That if Check No. __________ is negotiated, the payee hereby agrees to complete and sign an
affidavit of forgery for such check.
Signed by _________________________, as ____________________________, of the payee.
(name) (title)
___________________________
Payee Signature
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The foregoing affidavit was acknowledged before me, the undersigned Notary Public, by
____________________ this ________ day of _________________, 20___.
(name of payee)
________________________________
Notary Public
Send this ‘Affidavit of Lost/Stolen/Destroyed Check’ to:
Attn: Provider Reimbursement
Fidelis Care
25-01 Jackson Avenue
Long Island City, NY 11101
