Affidavit And Indemnity Bond - State Of North Carolina
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1BANKOPS-2-BUSINESS
AFFIDAVIT AND INDEMNITY BOND
I, ____________________________________on behalf of _________________________________________,
(Affiant)
(Business Name)
being first duly sworn, depose and say:
That
warrant(s)
numbered
____________________
for
$_______________________
dollars,
dated
________________, allegedly issued by __________________________________________, an agency of the State
of North Carolina and drawn on the State Treasurer,
___________ has/have not been received by this business,
___________ has/have been received by this business, was endorsed, but has/have since been destroyed,
stolen, or lost,
___________ has/have been received by this business, was not endorsed, and has/have since been
destroyed, stolen, or lost,
___________ has/have been examined by me and the first endorsement is not an authorized signature or
stamp of this business;
That I and this business did not cash the warrant(s) and have never benefited in any manner from said warrant(s);
That I and this business seek to have the State of North Carolina replace said warrant(s); and,
In consideration of the issuance of the replacement warrant(s) by the State of North Carolina, the
undersigned business is hereby held and firmly bound unto the State of North Carolina in the sum of
$_______________________ dollars (an amount equal to the sum of the warrant(s) involved herein), to be paid to
the State of North Carolina, to the payment whereof, well and truly to be made, the undersigned business binds itself
and its successors, firmly by these presents, so that the undersigned business and its successors shall at all times save
harmless and keep indemnified the State of North Carolina against any claim, demand, loss or expense of any
character, and against all loss and damages whatever that shall or may result at any time to the State of North
Carolina, or any agency thereof, arising out of and by reason of the issuance to the undersigned of the duplicate
warrant(s) in replacement of the warrant(s) hereinabove described.
WITNESS my hand and seal, this the _____________ day of __________________, ______
___________________________________
___________________________________________(SEAL)
Business Name
Signature of Affiant and Title
STATE OF _________________________________ )
COUNTY OF _______________________________ )
Subscribed and sworn to before me
This the __________ day of ______________________, ______.
____________________________________
Notary Public
My commission expires: ________________________
The statute of limitation for endorsement forgeries is three years. (G.S. 25-4-111)
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