GOVERNMENT OF 
THE VIRGIN ISLANDS OF THE UNITED STATES 
CHARLOTTE AMALIE, ST.  THOMAS, V.I.  00801 
-----0----- 
 
Department of Finance 
 
AFFIDAVIT OF LOST CHECK-----AGREEMENT OF INDEMNITY 
 
Whereas, the Commissioner of Finance of the Virgin Islands has caused to be issued and delivered to me 
a certain check No. _____________dated the ____ day of _______________, 20_____ in the sum of $____________ 
drawn on FirstBank Virgin Islands.                                                      
 
Whereas, the undersigned has represented to the Commissioner of Finance of the Virgin Islands and now 
declares that said check has been mislaid, lost, destroyed, not received  or bears a signature that is either 
unacceptable to the bank or not legible and has therefore applied to said Commissioner to issue a replacement  
check which said Commissioner has consented to do (after a 10 day waiting period) upon receiving the indemnity 
hereinafter contained: 
 
Now, therefore, the said (Name of Payee) __________________________________________ doth hereby agree 
to save harmless and indemnify the Government of the Virgin Islands from and against all claims and demands in 
respect to the said check; and from and against all damages, losses, cost, charges and expense which the 
Government 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 Commissioner of Finance 
forthwith if same shall be found. 
 
 
 
Name (print):__________________________________________   
Year:________________________________________________ 
                                                                                                                    
Signature:_____________________________________________ 
SSN/EIN:_____________________________________________ 
 
Spouse Name (print):_______________________________________      SSN (Spouse):_________________________________________ 
(Mandatory if taxpayer filed joint return.) 
 
 
 
 
 
 
 
 
 
Spouse Signature:____________________________________________ Mailing Address:_______________________________________ 
(Mandatory if taxpayer filed joint return.) 
 
 
 
 
 
            
                          _______________________________________ 
 
 
 
 
 
 
Date:_____________________________________   
 
 
                          _______________________________________ 
 
 
 
 
 
 
 
 
 
Telephone No:_________________________________________ 
Subscribed and sworn before me this: 
 
 
 
 
 
_______day of ______________________20_____ 
 
__________________________________________ 
                         Notary Public