AFFIDAVIT FOR RECEIPT OF UNCLAIMED FUNDS
FROM THE FAIRFIELD COUNTY TREASURER
State of ____________________ )
) SS:
County of ____________________ )
I, _______________________________________, being first duly sworn, state as follows:
(full name)
1. I am an agent of _________________________________________, legally
(company name)
authorized to make this affidavit and receive these funds.
2. My contact information is as follows:
______________________________________________
(title)
______________________________________________
(telephone number)
______________________________________________
(address number and street)
______________________________________________
(city), (state) (zip)
3. ___________________________________________ is a(n)
(company name)
___________________________________________ organized under the laws
(type of entity)
of the state of ________________________.
(state of organization)
4. ___________________________________________’s current address is:
(company name)
______________________________________________
(number and street)
______________________________________________
(city), (state) (zip)
5. Fairfield County Auditor’s warrant no. _________________ was issued to
(warrant no.)
___________________________________________ on __________________.
(company name) (warrant date)
6. Said warrant was not cashed, and the sum of $_______________ is due to
(amount of warrant)
__________________________________________ for said uncashed warrant.
(company name)
FURTHER AFFIANT SAYETH NAUGHT.
____________________________________
(signature)
____________________________________
(date)
Before me appeared the above named person who under oath or by affirmation did sign this
affidavit this ____________ day of _______________________, ______________.
____________________________________
Notary Public
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