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    Canada: Instructions Undertaking and Indemnity Cheques Issued by The Receiver General

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    Muhammad Haseeb Javed
    This document is an undertaking and indemnity form completed by Muhammad Haseeb Javed for a lost cheque. It certifies that he does not have cheque number 0407-34498239 for $125.92 covering his 2019 income tax refund. If the original cheque is found or another is issued, he agrees to reimburse the Crown for any losses. He also declares that he has not benefited directly or indirectly from cashing the cheque. The form must be signed and witnessed for amounts over $5,000.

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    Canada: Instructions Undertaking and Indemnity Cheques Issued by The Receiver General

    Uploaded by

    Muhammad Haseeb Javed
    2K views1 page
    This document is an undertaking and indemnity form completed by Muhammad Haseeb Javed for a lost cheque. It certifies that he does not have cheque number 0407-34498239 for $125.92 covering his 2019 income tax refund. If the original cheque is found or another is issued, he agrees to reimburse the Crown for any losses. He also declares that he has not benefited directly or indirectly from cashing the cheque. The form must be signed and witnessed for amounts over $5,000.

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    This document is an undertaking and indemnity form completed by Muhammad Haseeb Javed for a lost cheque. It certifies that he does not have cheque number 0407-34498239 for $125.92 covering his 2019 income tax refund. If the original cheque is found or another is issued, he agrees to reimburse the Crown for any losses. He also declares that he has not benefited directly or indirectly from cashing the cheque. The form must be signed and witnessed for amounts over $5,000.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views1 page

    Canada: Instructions Undertaking and Indemnity Cheques Issued by The Receiver General

    Uploaded by

    Muhammad Haseeb Javed
    This document is an undertaking and indemnity form completed by Muhammad Haseeb Javed for a lost cheque. It certifies that he does not have cheque number 0407-34498239 for $125.92 covering his 2019 income tax refund. If the original cheque is found or another is issued, he agrees to reimburse the Crown for any losses. He also declares that he has not benefited directly or indirectly from cashing the cheque. The form must be signed and witnessed for amounts over $5,000.

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    © All Rights Reserved
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    ••• Pubhc Works and

    Government Services
    Canada
    Travaux publics et
    Services gouvemementaux
    Canada
    UNDERTAKING AND INDEMNITY 535
    by the Receiver General
    For Cheques issued
    INSTRUCTIONS
    1
    · :.::u have not received or have lost your cheque, please complete this form of Undertaking and
    Yourma"lty In black or blue Ink and return It to the department responsible for the program and payment.
    • gnature must be witnessed by a non-family member
    NOTE:
    can revlIf the
    tho rt g I na I ch eque has b-n cashed, a copy of the' cashed cheque will
    . be sent to you so that you
    ew e endorsement.
    2
    • :~~;8t~he pay- or hol_der for value~• a federal, provincial or municipal government or agency, a financial
    th u /on, a partnership, a corporation or an Incorporated company, the form must be signed by the
    ::h or zed officer and their name and title must be printed below the signature.
    3• tehre _an authorlz4:d person signs this form on behalf of the payee or holder for value, the capacity or
    au onty under which it Is signed must be described.
    4. For amounts over $5,000, form PWGSC-TPSGC 540 - Affidavit (Cheques) may also be required.
    To: The Receiver General for Canada:
    I , the u ndersigned, MUHAMMAD HASEEB JAVED , hereby certify t hat
    Full Name of Payee or Holder for Value

    I do not have in my possession cheque num ber 04 07-34498239 dated _ _


    20_2
    _ 0_-_0_7_-_
    3_0 _ made payable
    Cheque Number

    to MUHAMMAD HASEEB JAVED

    or any cheque for$ 125. 92 * covering 2019 Income Tax Refund


    ------------
    Amount and Currency Program/Payment Type

    * Where applicable, this amount represents $ CAN converted at % exchange rate.

    J undertake to return the original cheque, uncashed, to the Receiver General for Carada ,;h(lu ld it ever come ,nto my possession. If
    another cheque is issued in place of the original cheque referred to above, I agree to ind~mn,fy (reimburse} and save harmless the Crown
    from any loss or expense incurred .
    I further declare that J have not caused benefit of any kind whatsoever to come to me eithec directly or indirectly through the cashing of
    the sa id cheque.
    Jf J benefit directly or indirectly through the cashing of the above-noted cheque, I will indemnify and save harmless the Crown from any
    loss or expense incurred.
    For payments in non-Canadian funds, J understand that by submitting this form that should I cash the above cheque, I could be charged
    an additional fee at the financial institution which is beyond the control of the Crown.
    TO BE COMPLETED WHEN AN AUTHORIZED OFFICER OR PERSON SIGNS ON BEH ALF OF PAYEE OR HOLDER
    FOR VALUE (SEE INSTRUCTIONS 2 AND 3 ABOVE) :
    I f u rther declare that I , the undersigned, _ _ _ ______ ____________ _ _ _ , am authorized
    Name of Authorized Officer

    as - - - - - - - - - - - - - - - --=- - - - - - - - - - - - - - - - - - - - - to sign this form .


    Title or Authority
    I/We u n derstand that making a false declaration is a criminal offense.
    Signature of Pay- or Holder for Value Signature of Witness

    Signature Date Signature Date


    N~~e and Addr~~s Qf Pa:;e~ or HQlder for Value Name and Address of Witness
    MUHAMMAD HA::,EE l::l JAVED
    39 CHARLTO N ST
    ST. JOHN 'S NL A l C 122

    Canada
    PWGSC-TPSGC 535 (2018-01)

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