AFFIDAVIT FOR RECEIPT OF UNCLAIMED FUNDS
FROM THE FAIRFIELD COUNTY TREASURER
State of ____________________ )
County of ____________________ )
I, _______________________________________, being first duly sworn, state as follows:
1. My current address is: ______________________________________________
(number and street)
(city), (state) (zip)
2. My Social Security Number is _________________________________________
3. Fairfield County Auditor’s warrant no. _________________ was issued to me
4. Said warrant was not cashed, and the sum of $_______________ is due to me
(amount of warrant)
for said uncashed warrant.
FURTHER AFFIANT SAYETH NAUGHT.
Before me appeared the above named person who under oath or by affirmation did sign this
affidavit this ____________ day of _______________________, ______________.