Form 1760 - Request For Warrant Cancellation printable pdf download

REQUEST FOR WARRANT CANCELLATION

A warrant cancellation request cannot be processed unless this form is completed to the fullest extent possible, signed, and returned

to the address listed at the bottom. Instructions are provided on page 2.

Member Data

ase Number: _____________________________

OAG C

Non-Custodial Parent’s Name: ________________________________________

Custodial Parent’s Name: ____________________________________________

Custodial Parent’s SSN: __________________________

Warrant Being Cancelled

Payee: ________________________________________

Mailed to: ______________________________________________________________________

Individual/Entity Requesting Warrant Cancellation and Replacement

Name or Business/Entity Title: __________________________________

Current Address: ______________________________________________________________________

Telephone Number: ___________________________________

Address Change Needed:

Yes

Reason for Warrant Cancellation and Replacement: __________________________________________________________

I, __________________________, certify that I have not negotiated (cashed or deposited) and will not negotiate the following

warrant(s):

Warrant Number

Issue Date

Warrant Amount

By signing this form, I am agreeing that:

• To my knowledge, the above referenced warrant was either lost, damaged, or destroyed.

• If the warrant was damaged and I have any portion of it, I will return it with this form to the address provided at the bottom of

this letter.

• If I receive this warrant in the future, I will return it to the address below and will indicate that the warrant is being returned

because it was cancelled and a replacement warrant was reissued.

A stop payment will be placed on the original warrant when this form is received. If I later cash the original warrant, I will be responsible for

any loss to a merchant, a check cashing entity, or a government agency. I hereby agree that the state may recover the amount of the loss for

honoring payment of the original warrant from child support collections that would otherwise be sent to me.

Signature of Requesting Party: ________________________________________

Date: ____________________

After signing this form, please return it to the address below:

Texas Child Support Disbursement Unit

P.O. Box 659730

San Antonio, TX 78265-9730

FAX: (210) 921-2394

November 2014

Form 1760

Form 1760 - Request For Warrant Cancellation