AFFIDAVIT 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: