__________________________________ ___________________________________
_____________________________________________________________________________
______________________________________
Illinois State Treasurer’s Office
Attn: Warrant Division/Forgery Section
400 West Monroe Street, Suite 401
Springfield, IL 62704-1848
Phone: (217) 782-4117
Fax: (217) 558-4028
FORGED WARRANT AFFIDAVIT
__________________________________, swears on oath and affirms that:
I am the payee named in the warrant(s) drawn by the State of Illinois Comptroller and drawn on the
State of Illinois Treasurer. I have examined the signature in my name that appears on the back of the
warrant(s). I did not make the indorsement on the warrant(s) and did not authorize another to make it.
I did not receive any benefit from the warrant(s) that totaled $___________ or authorize another
person to benefit on my behalf from the warrant(s) that are listed below or attached hereto.
Date warrant issued _________________ Warrant #_________________________
(If more than one warrant is involved, use additional paper to list the number and amount of
each warrant.)
CERTIFICATION
I certify to the best of my knowledge that the foregoing statements and the information I
provided in my claim form are true. I understand that a false statement in this affidavit will subject me
to penalties for perjury under Illinois law for making false sworn statements (5 ILCS 255/5). Perjury is
a Class 3 felony (720 ILCS 5/32-2).
Signature Social Security Number/Tax ID Number
TO BE COMPLETED BY NOTARY PUBLIC WITH SIGNATURE AND SEAL
Signed and sworn to before me
this _________ day of _____________________20_____.
Notary Public
9/2014
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