AFFIDAVIT OF LOST CHECK--AGREEMENT OF INDEMNITY
GOVERNMENT EMPLOYEES= RETIREMENT SYSTEM OF THE VIRGIN ISLANDS OF THE UNITED STATES GERS Complex-3rd Floor #3005 Orange Grove, Lot 5 48B-50C Kronprindsens Gade Christiansted St. Thomas, VI 00802 St. Croix, VI 00820-4313 AFFIDAVIT OF LOST CHECK--AGREEMENT OF INDEMNITY Whereas the Treasurer of the Government Employees= Retirement System has caused to be issued and delivered to me a certain check number dated the [DAY of check] day of [MONTH of check] 20[YEAR of check (last 2 digits)] in the sum of $[Check Amount] drawn on Banco Popular de Puerto Rico and Whereas the undersigned has represented to the Treasurer of the Government Employees= Retirement System and now declares that said check has been mislaid--lost--destroyed--stolen--not received and has applied to said Treasurer to give him/her another check which said Treasurer has consented to do (after a 15 day waiting period) upon receiving the indemnity hereinafter contained: Now therefore, the said [Paid To] doth hereby agree to save harmless and indemnity to the Government Employees= Retirement System from and against all claims an …
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GOVERNMENT EMPLOYEES= RETIREMENT SYSTEM OF THE VIRGIN ISLANDS OF THE UNITED STATES GERS Complex-3rd Floor #3005 Orange Grove, Lot 5 48B-50C Kronprindsens Gade Christiansted St. Thomas, VI 00802 St. Croix, VI 00820-4313 AFFIDAVIT OF LOST CHECK--AGREEMENT OF INDEMNITY Whereas the Treasurer of the Government Employees= Retirement System has caused to be issued and delivered to me a certain check number dated the [DAY of check] day of [MONTH of check] 20[YEAR of check (last 2 digits)] in the sum of $[Check Amount] drawn on Banco Popular de Puerto Rico and Whereas the undersigned has represented to the Treasurer of the Government Employees= Retirement System and now declares that said check has been mislaid--lost--destroyed--stolen--not received and has applied to said Treasurer to give him/her another check which said Treasurer has consented to do (after a 15 day waiting period) upon receiving the indemnity hereinafter contained: Now therefore, the said [Paid To] doth hereby agree to save harmless and indemnity to the Government Employees= Retirement System from and against all claims and demands in respect to the said check; and from against all damages, losses, cost, charges and expense which the Government Employees= Retirement System may sustain, incur or be liable for in consequence of it having issued a second check in lieu of the one above described. And the undersigned further agrees to return said check to the Treasurer of the Government Employees= Retirement System forthwith if same shall be found. Subscribed and sworn to before me this Signature: ________ day of 20 SS#: Date: Notary Public Address: My Commission expires Witness: Annuity Check Death Benefits Check Refund Check