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