1. I, , declare the following:
   I have been informed that University of California check number issued to in the amount of $ on .
   This check was drawn by The Regents of the University of California against its account maintained with Wells Fargo Bank.
2. I am the legal owner of this check, or I am entitled to possess it, but this check has been lost or destroyed due to the following circumstances:

3. The payee has not negotiated, deposited, or cashed this check except as follows:

4. If the original check should be found or otherwise placed in my possession after a new check has been issued to me in lieu of Check No. , I agree that I will not negotiate, deposit, or cash Check No. , but will deliver it to The Regents of the University of California for cancellation.
5. I agree that if a check is issued to me in lieu of the original check, I will indemnify and hold harmless The Regents of the University of California against loss, damage, expense, or any other liability which The Regents may suffer, either directly or indirectly, as a result of the new check being issued, or as a result of the originalcheck still remaining outstanding.
6. Pursuant to the foregoing declaration and subject to the foregoing conditions, I hereby request that The Regents issue a new check to me in lieu of Check No. .
7. Due to Campus policies, lost or stolen checks cannot be reissued for 21 days after the date of issuance.

I declare under penalty of perjury that the foregoing statements are true and correct. I acknowledge that I haveread, understand, and agree to the terms and conditions. By emailing my electronic signature I understand thatthe electronic documents and procedures presented in this application will replace the use of paper documentsand manual procedures. Electing to Submit by Email will indicate your agreement to the terms and conditions.