Form Ucb-18 Beneficiary Affidavit printable pdf download

BENEFICIARY AFFIDAVIT

STATE OF _______________________

COUNTY OF _____________________

Before the undersigned, an Officer Duly Authorized to Take Acknowledgments, personally appeared

_______________________________ who, being duly sworn, deposes and says that ________ is informed and

(he/she)

believes that the Comptroller of the State of Florida, did, on the ________ day of ______________, ___________ ,

issue a warrant on the Treasurer of the State of Florida payable to ____________________________________,

Social Security Number, ________________________________, for the sum of $______________, said warrant

bearing the Comptroller’s Warrant Number ____________________, having been issued in payment of

Reemployment Assistance Benefits, and that the proceeds of same are subject to payment to affiant as the

surviving ___________________, and request that the Department of Economic Opportunity authorize the

(Relationship to Deceased)

State Comptroller to issue a replacement warrant payable to the affiant as provided in Chapter 222.15 of the Florida

Statutes in the sum of $___________ to discharge this obligation; the original warrant has been surrendered to the

State Comptroller. The affiant further states that _____________________________ died _________________,

20_______, that the affiant is the surviving _____________________ of the decedent; and in the event prior claim

(Relationship to Deceased)

shall arise against this warrant _______ will reimburse the State of Florida for the amount of the warrant in

(He/She)

question.

****SUBMIT WITH COPY OF DEATH CERTIFICATE****

Sworn to and subscribed before me this

_______ day of ________________, 20______

Signature of Person Completing Affidavit

Signature of Notary Public

Current Mailing Address of Person Completing

Affidavit

Print, Type, of Stamp Commissioned

City, State, Zip Code

Name of Notary Public

________________________________________

Affiant Personally Known __________ OR

Commission Number and Expiration Date

Type and Number of Identification Produced:

OFFICIAL NOTARY STAMP REQUIRED.

_________________________________________

(SEAL IF APPLICABLE)

_________________________________________

UCB-18 (Rev. 03-12)

Form Ucb-18 Beneficiary Affidavit