Form DFS-A1-409 "Affidavit Attesting to Forgery" - Florida

What Is Form DFS-A1-409?

This is a legal form that was released by the Florida Department of Financial Services - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2014;
  • The latest edition provided by the Florida Department of Financial Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DFS-A1-409 by clicking the link below or browse more documents and templates provided by the Florida Department of Financial Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DFS-A1-409 "Affidavit Attesting to Forgery" - Florida

Download PDF

Fill PDF online

Rate (4.3 / 5) 30 votes
Department of Financial Services
Division of Accounting and Auditing – Bureau of Vendor Relations
AFFIDAVIT ATTESTING TO FORGERY
Please indicate the
Affidavit Attesting to Payee’s Non-Benefit of State Warrant (one
Completed by DFS Only
type of affidavit:
notarized copy required)
Affidavit Attesting to Forgery (three notarized copies required)
DFS Stop Order #
State of:
County Of
Before the undersigned, an Officer Duly Authorized to Take Acknowledgement, personally appeared the CLAIMANT
who, being duly sworn, deposes and says that the CLAIMANT (see below) is payee of a certain state warrant as
described below:
Claimant or Payee:
Warrant Payable To The Order Of:
FLAIR Account Code:
Warrant
Warrant
Number:
Date:
Amount:
and that the CLAIMANT has examined the endorsement on the warrant and did not write said signature nor did the
CLAIMANT authorize or procure the same to be written, but that same is a forgery; that CLAIMANT never received the
AMOUNT shown above by said warrant nor any part thereof, either directly or indirectly.
Claimant Signature:
Title (If Payee is not an individual):
Address:
City, State and Zip:
Two witnesses are required for payees who cannot sign their names. The Notary can count as one witness.
Witness 1:
Witness 2:
Address 1:
Address 2:
City St Zip1:
City St Zip2:
Information Marked by Asterisk (*) Must be Completed by the Notary
The State of Florida requires that a notary public seal shall be affixed to all notarized documents. This seal shall
include "Notary Public State of Florida" (or State you are notarized in). This seal shall also state name of Notary Public,
commission expiration date and a commission number. If your state does not require a commission number, then in
order for the State of Florida to accept this affidavit a letter with a copy of your state's Notary Public law(s) must be
attached to this affidavit attesting to forgery/payee’s non-benefit of state warrant.
* Sworn to and subscribed before me on
* Print or type name of person filing this affidavit:
* Print name of Notary Public:
* Signature of Notary Public
* State in which Notary is Commissioned
* Notary Stamp:
* Personally known?
* or Produced Identification?
* Type of ID produced
Name
Return Warrant to the Agency
Telephone
C/O:
Unit
Agency
Form DFS-A1-409
Revised 01/14
Department of Financial Services
Division of Accounting and Auditing – Bureau of Vendor Relations
AFFIDAVIT ATTESTING TO FORGERY
Please indicate the
Affidavit Attesting to Payee’s Non-Benefit of State Warrant (one
Completed by DFS Only
type of affidavit:
notarized copy required)
Affidavit Attesting to Forgery (three notarized copies required)
DFS Stop Order #
State of:
County Of
Before the undersigned, an Officer Duly Authorized to Take Acknowledgement, personally appeared the CLAIMANT
who, being duly sworn, deposes and says that the CLAIMANT (see below) is payee of a certain state warrant as
described below:
Claimant or Payee:
Warrant Payable To The Order Of:
FLAIR Account Code:
Warrant
Warrant
Number:
Date:
Amount:
and that the CLAIMANT has examined the endorsement on the warrant and did not write said signature nor did the
CLAIMANT authorize or procure the same to be written, but that same is a forgery; that CLAIMANT never received the
AMOUNT shown above by said warrant nor any part thereof, either directly or indirectly.
Claimant Signature:
Title (If Payee is not an individual):
Address:
City, State and Zip:
Two witnesses are required for payees who cannot sign their names. The Notary can count as one witness.
Witness 1:
Witness 2:
Address 1:
Address 2:
City St Zip1:
City St Zip2:
Information Marked by Asterisk (*) Must be Completed by the Notary
The State of Florida requires that a notary public seal shall be affixed to all notarized documents. This seal shall
include "Notary Public State of Florida" (or State you are notarized in). This seal shall also state name of Notary Public,
commission expiration date and a commission number. If your state does not require a commission number, then in
order for the State of Florida to accept this affidavit a letter with a copy of your state's Notary Public law(s) must be
attached to this affidavit attesting to forgery/payee’s non-benefit of state warrant.
* Sworn to and subscribed before me on
* Print or type name of person filing this affidavit:
* Print name of Notary Public:
* Signature of Notary Public
* State in which Notary is Commissioned
* Notary Stamp:
* Personally known?
* or Produced Identification?
* Type of ID produced
Name
Return Warrant to the Agency
Telephone
C/O:
Unit
Agency
Form DFS-A1-409
Revised 01/14
Department of Financial Services
Division of Accounting and Auditing – Bureau of Vendor Relations
All data, other than signatures, should be typed or printed. If any part of the form is not legible or the data is incomplete the
form will be returned.
Indicate the type of affidavit. Select ‘
Affidavit Attesting to Payee’s Non-Benefit of State Warrant’
when the warrant was
cashed without you endorsing it and you did not receive the funds. Select ‘
Affidavit Attesting to Forgery’ if your
signature was forged on the warrant when it was cashed and you did not receive the funds.
The DFS Stop Order Number is assigned by the DFS staff and will be assigned upon receipt of the completed form
or upon request of the Treasury.
State: Enter the state in which this affidavit is being notarized.
County: Enter the county within the State in which this affidavit is being notarized.
Claimant Name: Enter the name of the person who is making the request for a replacement warrant. This can be
the Payee (if an individual), a responsible officer of the Payee (if a company or organization) or a responsible State
Agency representative.
FLAIR account code: Enter the 29 digit FLAIR account code from which the original warrant was issued.
Payable to the order of: Enter the payee name as it was written on the original warrant.
Warrant number: Enter the ten-digit warrant number of the original warrant.
Warrant date: Enter the date of issuance of the original warrant.
Amount: Enter the dollar amount of the original warrant.
Signature: The person making the statement about the original warrant should sign his/her name here. This must
be the same person listed in the CLAIMANT name field at the top of the form.
Title: If the Payee is an individual, this field is N/A (not applicable). If the Payee is a company or organization,
please enter the title of the officer requesting the replacement warrant. If a state agency representative fills out the
form, list that person’s title here.
Address: Enter the address of the person making the request for duplicate.
City, State and Zip: Enter the City, State and Zip Code of the person making the request for replacement.
The Witness 1 and 2 information is only applicable if the Payee is a person who cannot sign his/her name. If they
mark their signature with an “X”, it must be witnessed by two persons, one of which can be the notary. The
address, city, state and zip code of the witnesses 1 and 2 must be completed.
Sworn to and subscribed before me this: The notary must enter the date he/she notarized the form.
The notary must print or type the name of the person making the request for the replacement warrant.
Signature and Stamp of the Notary Public; the name of the state in which the Notary Public is commissioned: The
Notary Public must provide the aforementioned information. If the document is notarized in another state, and that
state's notary laws do not require a commission number, then a letter stating such must accompany this form, a
photocopy of that state's notary laws must accompany the affidavit.
Print, type, or stamp the name of the Notary Public as Commissioned in this box.
Personally known or produced identification: In this box the Notary should place an "X" if the claimant is personally
known by the Notary. If not, leave blank.
Produced identification: In this box the Notary should place an "X" if the claimant IS NOT known by the Notary but
produces sufficient identification. If the Notary checks this box, enter the type of identification produced: Put a brief
description of the type of identification in this box. For example, "Florida Driver's license".
Return warrant to: This section must be filled out by the agency. Fill out the name of the person to whom the
replacement warrant should be returned, that person’s phone number, unit designation, and the agency for which
that person works. The replacement warrant will be sent to the Transmittal Section of the Department of Financial
Services for pick-up by the authorized agency courier.
Return the completed form to:
Department of Financial Services
Reconciliation Section
200 E Gaines Street
Tallahassee FL 32399-0354
Form DFS-A1-409
Revised 01/14
Page of 2