UNIVERSITY OF SOUTHERN INDIANA
Missing Check Affidavit
I, ___________________________________, did not receive nor endorse check # ___________
dated ________________ 19 _____, from the University of Southern Indiana, in the amount of
$________________ (__________________________________________________________)
My social security number is ______-_____-______.
_______________________________
(Signature) 
_______________________________
(Witness) 
Before me appeared ____________________, this _____ day of _____________, 19 _______.
Notary _________________________
_______________________________
(Printed Name) 
My Commission expires ____________
Commissioned in ___________County 
State of _______________. 

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