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. My current address is: ______________________________________________
(number and street)
______________________________________________
(city), (state) (zip)
2. My Social Security Number is _________________________________________
(SSN)
3. Fairfield County Auditor’s warrant no. _________________ was issued to me
(warrant no.)
on _____________________________.
(warrant date)
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.
____________________________________
(signature)
____________________________________
(date)
Before me appeared the above named person who under oath or by affirmation did sign this
affidavit this ____________ day of _______________________, ______________.
____________________________________
Notary Public
