Declaration of Loss

I herby certify that:

1.) I am the drawer, remitter or payee of the item. 2.) I can not reasonably obtain possession of the item because the item was destroyed, its whereabouts can not be determined, or it is in the wrongful possession of an unknown person or person that can not be found or is not amenable to service of process. 3.) The item was not properly endorsed by all parties at the time of the loss/theft. 4.) The loss was not the result of a transfer by me or a lawful seizure. 5.) I will not negotiate the item and, if found, will void the item and return the item to California Community Credit Union. (If the item is processed in error, I agree to hold California Community Credit Union harmless for non-payment of the item.) 6.) I agree to indemnify and hold California Community Credit Union harmless against any and all loss, damage, claim, liability or expense (including attorney’s fees) for which California Community Credit Union may become liable as a result of your compliance with my stop payment request.

The statements made herein are made under penalty of perjury and I warrant them to be true and correct.

I understand that if this claim is paid and the check is later presented for payment by a person having the rights of a holder in due course, I am obliged to either refund the payment to the credit union if the check is paid or pay the amount of the check to the person having rights of a holder in due course if the check is dishonored.