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MINNESOTA MANAGEMENT & BUDGET

AFFIDAVIT CONCERNING A STATE OF MINNESOTA PAYROLL WARRANT

Made Pursuant to Minnesota Statutes, Section 16A.46

STATE OF

COUNTY OF

________________________________________

______________________________________________

residing at

________________________________

___________________________________________________________________

(Affiant’s Name)

(Present Address)

County of

being first duly sworn, hereby deposes and

________________________________

_____________________________

says that:

State of Minnesota warrant number

Issued

_________________________________

____________________________________,

Employee ID

______________________________________________________________________

_______________________,

(Insert Name, Employee ID and Address on the Original Warrant)

Address

: ______________________________________________________________________________________________________

In the amount of

dollars, was

________________________________

____________________________________________________

______________________________________________________________________________________________________________

If the above warrant was received but lost, was it endorsed? θ Yes

θ No

And that if said original warrant ever comes into his/her possession, s/he will promptly return it to the Minnesota

Management & Budget, 658 Cedar St, Ste 400, Saint Paul, MN 55155-1616, and s/he will reimburse the state for any loss

which it may sustain by reason of any false statement, fault, or act on his/her part concerning this matter,

And that this affidavit is made for the purpose of securing the issuance of a duplicate warrant to him/her in the aforesaid

amount. You must sign this affidavit before a Notary Public.

_____________________________________________________

____________________________________________________

Signature of Affiant

Subscribed and sworn to before me this

day of

__________

_______________________, _____________

_____________________________________________________

My commission expires

_______________________________

NOTE: A duplicate warrant will be issued 1 – 3 days after Minnesota Management & Budget receives this affidavit

Person Sending Form

Phone Number

Fax affidavit to Lost Payroll Warrants at (651) 296-8325. Mail original affidavit to Minnesota Management & Budget,

Statewide Payroll Services, 658 Cedar St, Ste 400, Saint Paul, MN 55155-1616.

NOTICE: Name and Home Address are private data that will be available only to those individuals who need access to conduct legitimate business for

Minnesota Management & Budget and to taxing authorities. You are not legally obligated to provide it. However, we may not be able to process this

transaction without it.

FI-00604-03 (05/09)

Form Fi-00604-03 - Affidavit Concerning A State Of Minnesota Payroll Warrant - Minnesota Management & Budget

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