Who can submit this lost check form?

The proper owner, payee, or legal representative of the owner or payee may submit it for a City of Mercer Island check issued for goods or services.

What information does the affidavit request?

It requests the check number, amount, and date, along with the signer’s name, signature, signing location, address, phone number, and company name if applicable.

How do I submit the Lost Check Affidavit?

Email the completed form to accounts.payable@mercerisland.gov or mail it to Accounts Payable at City of Mercer Island, 9611 SE 36th Street, Mercer Island, WA 98040.

Mercer Island, WA · King County

No notary required

Lost Check Affidavit and Agreement of Indemnification

The proper owner, payee, or legal representative submits this affidavit and agreement when a City of Mercer Island check is lost, destroyed, or not received.

What this form is

Use this form when a City of Mercer Island check issued for goods or services has been lost, destroyed, or not received and, to the signer’s knowledge, has not been paid. The signer agrees to hold the city harmless if the original check is later presented and paid. The form requests check number, amount, date, signer and company details, contact information, and the city and state where signed.

Who needs it

The proper owner, payee, or legal representative of the owner or payee submits the form for a lost, destroyed, or unreceived city check.

How to submit it

Email the completed form to [email protected] or mail it to City of Mercer Island, Attn: Accounts Payable, 9611 SE 36th Street, Mercer Island, WA 98040.

About notarization

This document is signed without a notary; the signer certifies under penalty of perjury that the statement is true and correct, then signs and dates it.

How to submit this form

1
Download the Form
Download the Lost Check Affidavit and Agreement of Indemnification.
2
Complete the Form
Enter the check details and requested signer, company, and contact information.
3
Review and Sign
Certify the statement under penalty of perjury, then sign and date the form.
4
Submit to the City
Email the completed form to [email protected] or mail it to the Accounts Payable address shown on the form.

Frequently asked questions

Do I need a notary for the Lost Check Affidavit?: No. The form has no notary block. The signer certifies under penalty of perjury that the statement is true and correct, then signs and dates it.
Who can submit this lost check form?: The proper owner, payee, or legal representative of the owner or payee may submit it for a City of Mercer Island check issued for goods or services.
What information does the affidavit request?: It requests the check number, amount, and date, along with the signer’s name, signature, signing location, address, phone number, and company name if applicable.
How do I submit the Lost Check Affidavit?: Email the completed form to [email protected] or mail it to Accounts Payable at City of Mercer Island, 9611 SE 36th Street, Mercer Island, WA 98040.

Need something notarized?

This Lost Check Affidavit and Agreement of Indemnification doesn’t need a notary — but if you have another Mercer Island form that does, a commissioned online notary can help.