Revision Date: 07/10

AFFIDAVIT OF LOST, DESTROYED, OR STOLEN CASHIER’S CHECKS

Instructions: In order to make a claim for payment of a cashier's check which has been lost, destroyed, or stolen, you must either be
the remitter of the check (the person who purchased it from us) or the payee (the person to whom it was made payable), and you
must complete this form before a notary public and return it to us. Please note that your claim is not effective until the 90th
calendar day following the date the cashier's check was issued. Even if your claim has been received by us, we are permitted to pay
the check prior to the effective date of your claim to any person entitled to enforce it. In the event that your claim becomes effective
and is honored, you may be liable for the amount of the check should it subsequently be paid to a person having the rights of a
holder in due course.

State of )
)ss
Parish or County of )

Before me, the undersigned notary public in the jurisdiction set forth above, personally came and appeared

("Appearer") who, after being first duly sworn, testified and declared, under penalty of perjury, as follows:

1. Appearer is no longer in possession of the following cashier's check (the "Check") issued by Capital One, N.A.
(all blanks must be completed):

Number: Date Issued:

Amount: Name of Payee:

2. Appearer is (check one or both as applicable)

the remitter of the Check

the payee of the Check

3. Appearer's loss of possession of the Check was NOT the result of a transfer by Appearer or of a lawful seizure.

4. Appearer cannot reasonably obtain possession of the Check because (check one)

the whereabouts of the Check cannot be determined, or

the Check was destroyed, or

the Check is in the wrongful possession of an unknown person or of a person that cannot be found or is not amenable to
service of process.

5. Appearer intends this affidavit to constitute a Declaration of Loss and claim for payment of the Check. If Appearer is other than an
individual, the person executing this affidavit on behalf of Appearer warrants that he or she is duly authorized by Appearer to
make this affidavit and such claim.

6. Appearer will indemnify and hold Capital One bank harmless at all times from and against any and all claims, actions, proceedings,
losses and expenses, including counsel fees, which in any manner may be instituted or incurred by Capital One Bank by reason of
the issuance of a replacement check, or for any other matter arising out of the Check.

Signature

Printed Name

Title, if Appearer is other than an individual

Sworn to me and subscribed before me this day of ,

Notary Public