Election Worker Employment Application

Check Replacement Policy

Paychecks are mailed out to workers after an election. If you have lost or not received your paycheck within 4 weeks of the Election Day, please fill out this affidavit. Once submitted, we can process a new check for you. Please allow time for a new check to be issued and mailed.
LOST / NOT RECEIVED CHECK AFFIDAVIT

I swear or affirm that I have lost or have not received the check issued to me by the Lake County Supervisor of Elections.

Please enter all information below.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Please type date of birth
Check Number
Please type issued check number if known
Check Date

MonthDayYear
Please type issued check date if known
Check Amount
Please type issued check amount if known
Address to send replacement check*

Street Address

Street Address Line 2

CityState

Zip Code
Agreement & Signature

By submitting this affidavit, I affirm that the facts set forth are true and complete. I understand that if any false statements, omissions or other misrepresentations made on this affirmation may result in my immediate dismissal. In the event I obtain the original check referred to above, I shall immediately mail to the Lake County Supervisor of Elections, P.O. Box 457, Tavares, FL 32778.
Signature

Clear
Please use mouse to sign
Date*

MonthDayYear
Date
Should be Empty:

Check Replacement Policy