STATE OF WISCONSIN



LEGALDEPARTMENT OF CHILDREN AND FAMILIESDivision of Management ServicesBureau of FinanceP.O. Box 8916Madison, WI 53708-8916AFFIDAVIT OF LOST, DESTROYED, OR STOLEN CHECKS OR BENEFITSPersonal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)m), Wisconsin Statutes].AFFIDAVIT OF LOST, DESTROYED, OR STOLEN: FORMCHECKBOX DEFRA Check Payment FORMCHECKBOX Child Care FORMCHECKBOX Tax Intercept Payment FORMCHECKBOX EOG/LOC Payment FORMCHECKBOX WI Works (W-2) Payment FORMCHECKBOX DVR PaymentAgency FORMTEXT ?????Case or Provider Number (if applicable) FORMTEXT ?????Payment Amount$ FORMTEXT ?????Payment Date FORMTEXT ?????Replacement Date FORMTEXT ?????Check Number (Missing Check) FORMTEXT ?????Benefit/Issuance Number (If applicable) FORMTEXT ?????Claimant Name (please print) FORMTEXT ?????Telephone number FORMTEXT ?????Current address FORMTEXT ?????4. Date moved to this address FORMTEXT ?????Previous address (if you moved within the last month) FORMTEXT ?????6. Date moved to this address FORMTEXT ????? 7. Did you notify the agency of your move? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Not Applicable8. Do you have a locked mailbox? FORMCHECKBOX Yes FORMCHECKBOX NoAFFIDAVIT 9.My payment of allotment is missing because: FORMCHECKBOX It was not received through the mail FORMCHECKBOX It was received, but subsequently destroyed FORMCHECKBOX It was stolen from my mailbox FORMCHECKBOX It was stolen or extorted from FORMCHECKBOX me, in person FORMCHECKBOX a member of my family (name) FORMTEXT ????? FORMCHECKBOX Other (specify) FORMTEXT ?????NOTE: If a witness was present, print witness’ name, address and telephone number in #1110.(FOOD STAMPS ONLY) FORMCHECKBOX Good FORMCHECKBOX Damaged FORMCHECKBOX Sealed FORMCHECKBOX Unsealed11.Was a witness present when the envelope was opened? FORMCHECKBOX Yes FORMCHECKBOX NoIf “Yes,” print witness’ name, address, and telephone number FORMTEXT ?????12.I certify, under penalty of criminal law, that neither I nor any member of my family (household) has received, directly or indirectly, or spent the payment of Food Stamp allotment described as missing above. I agree that if I find or subsequently receive the missing payment or allotment, I will return it to the agency. The information above is true and complete to the best of my knowledge. I understand that I may be subject to criminal penalties if any part of the above information is false.Signature of claimant/participant (or, for Food Stamps only, participant’s representative) FORMTEXT ?????Claimant/participant signature FORMTEXT ?????Signature of witness FORMTEXT ?????Witness signature FORMTEXT ?????Witness’ address FORMTEXT ?????Signature of agency/tribal representative (if applicable) FORMTEXT ?????Agency/tribal representative signature FORMTEXT ????? ................
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