Free 50712.PDF - Indiana

AFFIDAVIT FOR USE BY FINANCIAL INSTITUTIONS FOR WARRANT REPLACEMENT
State Form 50712 (11-01) Approved by State Board of Accounts, 2001

COMES NOW:___________________________________________________ and duly sworn, deposes and says: That affiant is the holder in due course of an Auditor of State of Indiana warrant as described below. WARRANT NUMBER:________________________, IN THE AMOUNT OF $________________________ DATED:_____________________, AND MADE PAYABLE TO__________________________________________________________________________was lost or destroyed under the following circumstances:___________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________. The original payee of said warrant has no claim to the proceeds of said warrant. The affiant has made no claim against any other person or corporation by reason of the loss of said warrant and no such claim will be made. The affiant agrees to indemnify the State of Indiana against any loss that it may sustain by reason of the payment of the original warrant. This affidavit is made for the sole purpose of inducing the Auditor of State's office to issue a duplicate of the aforementioned warrant, and cross endorse the same to the order of the undersigned.

AFFIANT'S ADDRESS_________________________________________________________________ SIGNED_________________________________________________, TITLE_____________________________________________. STATE OF_____________________________ COUNTY OF___________________________ Subscribed and sworn to before me, a Notary Public in and for said County and State the __________ day of _________________________. ___________________________________________ Notary Public My commission expires :_____________________. County of Residence: _________________________.