Replacement Check Declaration

REVISED 10.12.17

Name__________________________________ Name of Production__________________________________

Social Security Number___________________ Production Company__________________________________

Check Number(s)________________________ Work Date(s)_____________________________________

Check Date(s)___________________________  Current Year

 Prior Year
Net Check Amount(s)_____________________

This declaration is made voluntarily and for the purposes of obtaining the proceeds of the above referenced
check(s). I understand that making a false representation through this declaration constitutes fraud and may
subject me to civil liability and/or criminal prosecution. I declare under penalty of perjury of the laws of the
United States, that the following is true and correct (please check one):

□ I never received the above referenced check(s) or proceeds issued by CAPS or any part thereof.
□ I never received the above referenced check(s) or proceeds due to an incorrect address supplied by
me.
□ I received the above referenced check, but I lost it.
□ The above referenced check was stolen.

Should this declaration be incorrect now or at any time in the future, I agree to indemnify CAPS, LLC for all
costs and damages, including but not limited to the gross amount of monies I receive from CAPS, LLC, bank
fees or penalties, fees charged by other third parties, costs of collection and attorneys’ fees. I further agree
immediately to deface (by marking as “void”) and return the above referenced check(s) to CAPS, LLC if the
check(s) come(s) into my possession.

Signed ______________________________________________ Date ______________________________

Print Name __________________________________________ Telephone _________________________

Address
City, State, Zip Code ___________________________________ E-mail ____________________________

Office Use Only

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