Form 42850 - Affidavit For Lost Or Not Received Warrant
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1AFFIDAVIT FOR LOST OR NOT RECEIVED WARRANT
State Form 42850 (R/06-01)
Approved by State Board of Accounts 2001
Approved by the Auditor of State 2001
Warrant Payable To (Name):
Street Address:
City, State, Zip:
Telephone Number with Area Code:
Warrant Number:
Warrant Date:
Warrant Amount:
I am requesting a rewrite of the above described warrant for the following reason: (check one box)
I have not received this warrant
I have received this warrant but it was lost, stolen or destroyed. This happened as follows:
I certify under penalty of perjury that the above information is true and correct and that I have not at any time received payment on
this warrant or any other warrant for payment of this claim. I understand that payment on this warrant will be stopped, and I may
not cash this warrant if it is received. If I receive this warrant, I will return it to the Indiana Auditor of State at 240 State House, 200
W. Washington St., Indianapolis, IN 46204-2793
Signature of Requestor:
Date subscribed and sworn to Notary Public:
Printed Name of Requestor:
Social Security Number or Tax ID Number:
STATE OF: __________________________________________________
STATE OF ________________________________________________
SS:
COUNTY OF_________________________________________________
Subscribed and sworn to before me, a Notary Public, in and for said County and State, this ________ day of ________________,20______.
Signature of Notary Public:
County of Residence:
Printed or Typed Name of Notary Public:
Date Commission Expires:
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