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Declaration of' Loss and lndeniniv� agreementBankof America
<br /> i ( W"I I D 1 N I I \1 Stop Payprcifit Form use in PJi siei:e�C\Cept cailfol-nia)
<br /> a,Stop Placed? 1., ❑ j, s h. 4
<br /> O:P\ Itu,-
<br /> Required fields (ire idelijific(I j/1 &1o'it,jill Stop PaNment cracking
<br /> Cashier's / Official Check
<br /> • -k stop p:iN inent maN not be placed by the claimant for arts reason other than lost,stolen or destroN ed.
<br /> • A rcpid�c ch,:Crl o, to ar" E,0,:11>cd uinil th_��)!-'calco-idar di,, aft�ikic Iss_!,�L:",t,�
<br /> Personal Money Order
<br /> • A stop payment cannot be placed if the payee line ,Nis not completed.
<br /> 'Viic: I or lines of htjsincsN supportintz tiers ice recjua,tN from clients is ho submit the form (in behalf of a customer. indicate of
<br /> ',mcric.i on helmif;it trust micr name).
<br /> Narne of Claimant Claimant is: Day time Phone Current Date
<br /> APurchaser R Pm cc
<br /> e- Bank of Aincrica(Ichcck,issued for"bank use only)
<br /> � �I S�/ f 01 1 US 1=2
<br /> CI State Zip Code
<br /> 2)",tj
<br /> M C; 1-7
<br /> Address ot'C!A!n1arlt I _TY I
<br /> Cashier's/Official Chcck./Nlonc} Order Account Cashier's/Official CheckAlloncy Order Serial Date of
<br /> Number (List the same account number on 2"'Page) Number (List the same check number on 2"'Page) Cashier's!Official Check I Money Order
<br /> t M,, -3 'ol _20/-7
<br /> Cashier's Official Check 'NloncN Order \niount Pu chaser Payee 4.516,J
<br /> I
<br /> 3 r�j, C,e-& -
<br /> Rg=il In mc�+/ Mij,
<br /> Cashier's/Official Check Personal honey Order
<br /> Claimant is pates or purchaser-Reason for Stop Pay nient (Please check one) Ro son otop Payment(Please check one)
<br /> -1 �tolcii F Dc�tF,�cl S
<br /> ,,t tolen El Dcitro%cd [I Di;pute
<br /> Check issued for-bank use"only -Reason for stop pay ruent(Please check one) /Was NloncN Order payee line complete? , El N es El No NEW
<br /> o,t D St,,Icll El DQstr,_),,cJ
<br /> If No is checked--Stop Payment cannot be placed if the
<br /> ❑ (),JIcr(I c1h!111} ii_,ceptx-.x Bank )!'Amcri,a Mtcl`11,11 Ul',0111\ -RCLI't'll RcLjiIIrcd) payee line is blank. Do not proceed ),Nith rest of this form.
<br /> jJ& Note: Bs checking"other",the line of business requesting the stop
<br /> pay ment herein accepts all liability if the check presents for
<br /> payment. A Liabilit,. Acceptance'Form is required.
<br /> il-i C c r!J 1 r S J tshcn Io,t,t, 1 1,dctro}cd" Clainiant requests reirnburscnientlrepl�lcemcrit as folloiss(Please check one)
<br /> nkllo"kn credit to :1,inri il�,:jn*
<br /> \_,o.:nt narn, 1xr LI r: En'.It% state
<br /> Important-Required
<br /> Cashier's 'Official Check-Read Part A and complete Part C Personal Money Order- Read Part B and complete Part C
<br /> Part \
<br /> PaNCC Purchaser's Claim for Reimbursement of lost, stolen or destroyed Cashier's Official Ch e c 1,
<br /> 1; 4,
<br /> J!_
<br /> v,l, 1 X, T, `I_1F,i'_,,,_!,,
<br /> H'I:", I)�_l 1-J, �a Ii
<br /> T" .1!' 12,
<br />
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