Government of Ontario: Ministry of Community and Social Services
Family Responsibility Office

I, (Name in Full) of (Address, Street Name and Number, City/Town, Concession, Province and Postal Code) in the County / District / Regional Municipality of make oath and say as follows:

1. I certify that I have not received, or have received and subsequently lost cheque number dated 20 .
   For the sum of (enter the sum in words) $ (enter the sum in figures) alleged to have been drawn by the Family Responsibility Office on the ROYAL BANK OF CANADA, Toronto, Ontario In respect of Family Responsibility Office Case Number:
2. I further certify that I have not received payment of such amount by any other means.
3. In the event of a duplicate cheque being issued made payable to me, I agree not to cash, endorse, or transfer the original cheque should it ever come into my possession, but to return the same to the said Ministry of Community, Family and Children's Services.
4. I further agree that should the Minister of Finance Suffer any loss whatsoever by reason of the issue of a duplicate cheque, I shall indemnify him against all costs, damages, interest and expenses which he may bear or incur as a result of any claims being made by me or my assignees, endorsees or transferees where such claim is made on the original cheque or the duplicate cheque, and I hereby authorize the Minister of Finance to withhold the amount of such loss for any future payment due me by him.
5. According to the best of my knowledge, information and belief, this cheque has not been cashed nor has same been deposited to any of my accounts.

Sworn before me at the of In the County (or District) of this day of A.D. 20 (A Commission for Taking Affidavits) (Claimant's Signature)

Instructions: Mail your completed form to:
Family Responsibility Office
P.O. Box 220,
Downsview ON
M3M 3A3

FOR MINISTRY USE ONLY

Batch Number:
Processed by: Telephone Number:
Representative: Telephone Number: