David Douglas School District #40

<School Name>

<Address> / <City>, <State> <Postal Code>

Telephone: (503) <XXX-XXXX> / Fax: (503) <XXX-XXXX>

<Date>

<Company>

<Address>

<City>, <State> <Postal Code>

RE: Oregon Unclaimed Property Due Diligence Notification:

Our records indicate that we issued a check to you that does not appear to have cleared our bank as of the date of this letter. Due to the amount of time that has elapsed the original check is no longer valid.

Check # <Check Number>

Date <Date>

Amount <Amount>

Description <Description>

If these funds are not owed to you or if you would like to donate the funds back to <School Name> please mark the box below.

1 Please donate to <School Name>

To request a reimbursement because the check has been lost or destroyed, please mark the box below and complete the form on the reverse side of this letter. The form must be filled out completely and returned to <School Name>, attention <Bookkeeper/Secretary>.

1 Duplicate requested

PLEASE NOTE: We must receive your response within 30 days from the date of this letter or the funds will be submitted to the Oregon Department of State Lands to be held as abandoned property.

If you have any questions, please call 503-<XXX-XXXX>.

Sincerely,

<School Name>

Attn: <Bookkeeper/Secretary> – <School Name>

<Address>

<City>, <State> <Postal Code>

David Douglas School District #40

<School Name>

Payee Declaration:

I am the lawful owner, payee, or legal representative of the lawful owner or payee, of the <School Name> check referred to above.

The check has been (check one): ____ lost, ____ stolen, or ____ destroyed, and has not been repaid.

If the original check being reported as lost, stolen, or destroyed is located later, it will be immediately returned to <School Name> for cancellation. Under no circumstances will the original check be presented for payment.

I furnish this statement in compliance with Oregon Revised Statute 293.475 to obtain, from <School Name>, a duplicate check for the same amount as the original.

Payee Name: ______Phone (____) ______

Payee Address: ______

______

Attention: ______Check: ______

Signature: ______Date: ______

<School Name> Use

Reissued Check # Dated: