DSHS Form 09-013 "Vendor Affidavit of Lost, Stolen, or Destroyed Warrant" - Washington

What Is DSHS Form 09-013?

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

Form Details:

  • Released on June 1, 2016;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 09-013 by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 09-013 "Vendor Affidavit of Lost, Stolen, or Destroyed Warrant" - Washington

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DSHS Affidavit of Lost, Stolen, or Destroyed Warrant
STATE OF WASHINGTON
)
RETURN TO:
OAS Use
)
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
Only
)
OFFICE OF ACCOUNTING SERVICES (OAS)
PO BOX 45842
OLYMPIA WA 98504-5842
I,
(print name), having been duly sworn, depose and say that I am the
proper owner, payee, or legal representative of such owner or payee of the state of Washington’s
Warrant Number
, dated
, in the amount of $
, and that
said warrant has been lost, destroyed or not delivered to me and to the best of my knowledge has not been
paid. If the original warrant is subsequently found, I will return the warrant to OAS. I agree that if I (as an
employee or vendor) cash both warrants, the full amount listed above may be withheld from my next
payment(s).
PAYEE SIGNATURE
PAYEE PHONE NUMBER
MAILING ADDRESS
CITY
STATE
ZIP CODE
I am a:
DSHS employee
Other:
NOTARY SEAL
State of
County of
I certify that I know or have satisfactory evidence that
(name of person) is the person who appeared before me, and said person acknowledged
that (he/she) signed this instrument and acknowledged it to be (his/her) free and voluntary
act for the uses and purposes mentioned in the instrument.
Dated
Signature
Title
My appointment expires
WITNESSES: REQUIRED ONLY IF PAYEE SIGNED BY MARK (X) ABOVE
WITNESS’ SIGNATURE
DATE
PRINT NAME (WITNESS’ NAME) HERE
1
STREET ADDRESS
CITY
STATE
ZIP CODE
WITNESS’ SIGNATURE
DATE
PRINT NAME (WITNESS’ NAME) HERE
2
STREET ADDRESS
CITY
STATE
ZIP CODE
FOR DSHS USE ONLY
WARRANT CANCELLATION AUTHORIZATION
AGENCY/SUB
ISSUE DATE
BIENNIUM
WARRANT NUMBER
NAME
REGISTER NUMBER
ADDRESS
CITY
STATE
ZIP CODE
FUND
AMOUNT
AUTHORIZED BY
TELEPHONE
TOTAL
Original to Office of Accounting Services.
DSHS 09-013 (REV. 06/2016)
DSHS Affidavit of Lost, Stolen, or Destroyed Warrant
STATE OF WASHINGTON
)
RETURN TO:
OAS Use
)
DEPARTMENT OF SOCIAL AND HEALTH SERVICES
Only
)
OFFICE OF ACCOUNTING SERVICES (OAS)
PO BOX 45842
OLYMPIA WA 98504-5842
I,
(print name), having been duly sworn, depose and say that I am the
proper owner, payee, or legal representative of such owner or payee of the state of Washington’s
Warrant Number
, dated
, in the amount of $
, and that
said warrant has been lost, destroyed or not delivered to me and to the best of my knowledge has not been
paid. If the original warrant is subsequently found, I will return the warrant to OAS. I agree that if I (as an
employee or vendor) cash both warrants, the full amount listed above may be withheld from my next
payment(s).
PAYEE SIGNATURE
PAYEE PHONE NUMBER
MAILING ADDRESS
CITY
STATE
ZIP CODE
I am a:
DSHS employee
Other:
NOTARY SEAL
State of
County of
I certify that I know or have satisfactory evidence that
(name of person) is the person who appeared before me, and said person acknowledged
that (he/she) signed this instrument and acknowledged it to be (his/her) free and voluntary
act for the uses and purposes mentioned in the instrument.
Dated
Signature
Title
My appointment expires
WITNESSES: REQUIRED ONLY IF PAYEE SIGNED BY MARK (X) ABOVE
WITNESS’ SIGNATURE
DATE
PRINT NAME (WITNESS’ NAME) HERE
1
STREET ADDRESS
CITY
STATE
ZIP CODE
WITNESS’ SIGNATURE
DATE
PRINT NAME (WITNESS’ NAME) HERE
2
STREET ADDRESS
CITY
STATE
ZIP CODE
FOR DSHS USE ONLY
WARRANT CANCELLATION AUTHORIZATION
AGENCY/SUB
ISSUE DATE
BIENNIUM
WARRANT NUMBER
NAME
REGISTER NUMBER
ADDRESS
CITY
STATE
ZIP CODE
FUND
AMOUNT
AUTHORIZED BY
TELEPHONE
TOTAL
Original to Office of Accounting Services.
DSHS 09-013 (REV. 06/2016)