Affidavit of Lost, Stolen, or Destroyed Warrant
| | Affidavit of Lost, Stolen, or Destroyed Warrant |
|STATE OF WASHINGTON ) |RETURN TO: |FSA Use Only |
|) |Washington State Health Care Authority | |
|) |Financial Services/Accounting | |
| |PO Box 42691 | |
| |Olympia, WA 98504-2691 | |
| | | |
|I, (print name), having been duly sworn, depose and say that I am the proper owner, payee, or legal representative of such owner or payee of | |
|the state of Washington’s | |
|Warrant Number , dated , made out to the order | |
|of in the amount of $ , and that said warrant has been lost, destroyed or not delivered to me and to the best of my knowledge has not | |
|been paid. If the warrant is subsequently found, I will return the warrant. | |
| | |
|Payee signature Payee phone number | |
| | |
|Mailing address City State ZIP Code | |
|NOTARY SEAL |State of |
| |County of |
| |I certify that I know or have satisfactory evidence that |
| |(name of person) is the person who appeared before me, and said person acknowledged that (he/she) signed this instrument |
| |and acknowledged it to be (his/her) free and voluntary act for the uses and purposes mentioned in the instrument. |
| |Dated Signature |
| |Title My appointment expires |
| |
|WITNESSES: REQUIRED ONLY IF PAYEE SIGNED BY MARK (X) ABOVE |
|1 |Witness’ signature Date |Print name (witness’ name) here |
| | | |
| |Street address City State ZIP Code |
| | |
|2 |Witness’ signature Date |Print name (witness’ name) here |
| | | |
| |Street address City State ZIP Code |
| | |
| |
|FOR HCA USE ONLY |
|HCA unit contacted |HCA staff name |HCA staff telephone |Issue date |
| | | | |
|New check number |P1 ID number |Register number |Warrant number |
| | | | |
|Payee name |Fund |Amount |
| | | |
|Payee address City State ZIP Code |Reissued by |Telephone |
| | | |
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