Indiana Affidavit for Lost or Not Received Warrant

This article provides step-by-step instructions to complete the "Indiana Affidavit for Lost or Not Received Warrant" (State Form 42850), used to request a replacement for a lost, stolen, destroyed, or not received payment warrant.

The “Indiana Affidavit for Lost or Not Received Warrant” (State Form 42850) is an official form issued by the State of Indiana that allows individuals or entities to request a replacement for a lost, stolen, destroyed, or not received state-issued warrant (check). A warrant is a payment instrument issued by the state, often for tax refunds, benefits, or other payments. By filing this affidavit, the individual certifies under penalty of perjury that they did not receive payment or that the original warrant is no longer usable. Filing this affidavit ensures that the state can issue a stop payment on the original warrant and reissue a new one. The form must be notarized and submitted to the Indiana State Comptroller for processing.

How to File the “Indiana Affidavit for Lost or Not Received Warrant”

To file the affidavit, the requester must:

  1. Complete the form with accurate details about the lost, stolen, destroyed, or unreceived warrant.
  2. Have the affidavit notarized by a notary public.
  3. Submit the completed form to the Indiana State Comptroller at the following address:
    Indiana State Comptroller
    240 State House
    200 W. Washington St.
    Indianapolis, IN 46204-2793

Ensure all information is correct and that the form is signed and notarized before submission. If the form is incomplete or incorrect, it may delay the issuance of a replacement warrant.

How to Complete the Indiana Affidavit for Lost or Not Received Warrant Form 2

How to Complete the Indiana Affidavit for Lost or Not Received Warrant Form

Section 1: Warrant Information

  1. Warrant Number: Enter the warrant number printed on the original warrant. If you do not have this information, contact the issuing state office to retrieve it.
  2. Warrant Date: Provide the date the warrant was issued.
  3. Warrant Payable To (Name): Enter the name of the individual or entity to whom the warrant was issued.
  4. Street Address: Write the full mailing address of the payee, including city, state, and ZIP code.
  5. Telephone Number with Area Code: Provide a phone number where you can be reached for follow-up questions regarding the affidavit.
  6. Warrant Amount: Enter the face value of the warrant (the dollar amount).

Section 2: Reason for Replacement Request

  • Check One Box: Select the reason why you are requesting a replacement warrant:
    • I have not received this warrant: Check this box if the warrant was never delivered to you.
    • I have received this warrant but it was lost, stolen, or destroyed: Check this box if you did receive the warrant but it is no longer in your possession. You must also provide an explanation of what happened to the warrant in the space provided (e.g., “The warrant was accidentally shredded” or “The warrant was stolen from my mailbox”).

Section 3: Certification and Signature

  1. Certification Statement: Read the certification carefully. By signing, you declare under penalty of perjury that:
    • The information provided on the affidavit is true and correct.
    • You have not received payment on this warrant or any other warrant related to this claim.
    • If you receive the original warrant after submitting the affidavit, you will not cash it and will return it to the Indiana State Comptroller.
  2. Signature of Requestor: Sign your name in the designated space to certify the affidavit.
  3. Printed Name of Requestor: Print your full name below your signature.
  4. Social Security Number or Tax ID Number: Enter your Social Security Number or Tax Identification Number for identification purposes.

Section 4: Notarization

  1. State and County: Enter the state and county where the notarization is taking place.
  2. Date Subscribed and Sworn To: Provide the date when the affidavit is signed and notarized.
  3. Notary Public Information:
    • Printed or Typed Name of Notary Public: The notary public must print or type their name.
    • Signature of Notary Public: The notary must sign the form to confirm the notarization.
    • County of Residence: The notary must include their county of residence.
    • Date Commission Expires: Provide the expiration date of the notary public’s commission.
  4. Requestor’s Signature Before Notary: You must sign the affidavit in the presence of the notary public.

Additional Considerations

  1. Accuracy is Critical: Ensure all information is correct and matches the details of the warrant issued by the state. Incorrect information may delay the replacement process.
  2. Supporting Documentation: Attach any relevant documentation, such as copies of correspondence with the issuing office, if applicable.
  3. Stop Payment on the Original Warrant: Once the affidavit is submitted, the Indiana State Comptroller will place a stop payment on the original warrant. If you receive the original warrant after submitting the affidavit, do not cash it. Instead, return it to the Comptroller’s office.
  4. Processing Time: Allow several weeks for the replacement warrant to be issued. Contact the Indiana State Comptroller for updates if necessary.

By following these detailed instructions, you can accurately complete and file the “Indiana Affidavit for Lost or Not Received Warrant” to request a replacement payment from the State of Indiana. Ensure all sections are properly filled out, and don’t forget to have the affidavit notarized before submission.

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