STATE OF NEBRASKA
John Murante, State Treasurer
State Capitol, Suite 2005 | P.O. Box 94788 | Lincoln, NE 68509 | 402-471-2455 | treasurer.nebraska.gov
AFFIDAVIT REGARDING LOST OR MISSING STATE WARRANT
1. I am the individual who is lawfully entled to receive this STATE WARRANT from the State of
2. As of the date of this adavit, I have lost or never received this STATE WARRANT.
3. I understand that aer a replacement state warrant is issued, the original STATE WARRANT will be
canceled. If I later come into possession of the original STATE WARRANT, it is my responsibility to
nofy the Nebraska State Treasurer at (402) 471-2455, opon 5.
4. I understand that any misrepresentaons I make on this adavit could subject me to prosecuon
for perjury and/or other penales. I also understand that if I aempt to cash the original STATE
WARRANT that it will be returned to the bank and will not be honored by the State of Nebraska.
Lost or Missing State Warrant Informaon
(Complete the following three elds with informaon for the lost or missing state warrant)
Number: Date: Amount:
The warrant associated with the informaon you list above, for the enrety of this page, shall be referred to as “STATE WARRANT”.
Aant Signature: Date:
Date the foregoing instrument was acknowledged before me [Notary]:
State of Nebraska, County of: