Free Form.PDF - Indiana

AFFIDAVIT FOR LOST OR NOT RECEIVED WARRANT State Form 42850 (R/06-01) Approved by State Board of Accounts 2001 Approved by the Auditor of State 2001

Warrant Payable To (Name):

Street Address:

City, State, Zip:

Telephone Number with Area Code:

Warrant Number:

Warrant Date:

Warrant Amount:

I am requesting a rewrite of the above described warrant for the following reason: (check one box) I have not received this warrant I have received this warrant but it was lost, stolen or destroyed. This happened as follows:

I certify under penalty of perjury that the above information is true and correct and that I have not at any time received payment on this warrant or any other warrant for payment of this claim. I understand that payment on this warrant will be stopped, and I may not cash this warrant if it is received. If I receive this warrant, I will return it to the Indiana Auditor of State at 240 State House, 200 W. Washington St., Indianapolis, IN 46204-2793

Signature of Requestor:

Date subscribed and sworn to Notary Public:

Printed Name of Requestor:

Social Security Number or Tax ID Number:

STATE OF ________________________________________________ STATE OF: __________________________________________________ SS: COUNTY OF_________________________________________________

Subscribed and sworn to before me, a Notary Public, in and for said County and State, this ________ day of ________________,20______.

Signature of Notary Public:

County of Residence:

Printed or Typed Name of Notary Public:

Date Commission Expires: