Form AD40 "Certification of Claimant" - Oregon

What Is Form AD40?

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

Form Details:

  • Released on July 13, 2021;
  • The latest edition provided by the Oregon Department of Administrative 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 fillable version of Form AD40 by clicking the link below or browse more documents and templates provided by the Oregon Department of Administrative Services.

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Download Form AD40 "Certification of Claimant" - Oregon

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Submit
AD40
STATE OF OREGON
CERTIFICATION OF CLAIMANT
(To be used by State Agencies to cancel warrants two years after issue date.)
I, ________________________________________, certify to all of the following:
(Please Print)
1. That I am employed as _______________________________________ (Title) at the
governmental agency___________________________________________________.
2. That the mailing address of the agency is ___________________________________
___________________________________
___________________________________
3. That the original instrument was a warrant of the State of Oregon with date of issue
______________, numbered ____________, in payment for Doc #(s) ____________,
drawn in favor of payee _____________________________________, in the sum of
$ ___________________, furnished by the State of Oregon.
4. That the original instrument has been ( ) lost, ( ) destroyed or ( ) stolen and has not
been entered into our records.
5. That I furnish this statement to authorize the Dept of Administrative Services of the
State of Oregon the cancellation of the original instrument once two years have
passed from the date of issue.
6. I have the authority to approve the expense that may be created in the event the
cancelled warrant is cashed.
7. My agency accepts the responsibility of this cancelled warrant and will work toward
reimbursement from this payee in the event the original is cashed.
Agency Name ___________________________________
Signed _________________________________________
(Accounting Manager)
Title ___________________________________________
Date ___________________________________________
Please submit this form to WarrantStopCancel.1.SFMS@oregon.gov
Revised: 7/13/2021
Submit
AD40
STATE OF OREGON
CERTIFICATION OF CLAIMANT
(To be used by State Agencies to cancel warrants two years after issue date.)
I, ________________________________________, certify to all of the following:
(Please Print)
1. That I am employed as _______________________________________ (Title) at the
governmental agency___________________________________________________.
2. That the mailing address of the agency is ___________________________________
___________________________________
___________________________________
3. That the original instrument was a warrant of the State of Oregon with date of issue
______________, numbered ____________, in payment for Doc #(s) ____________,
drawn in favor of payee _____________________________________, in the sum of
$ ___________________, furnished by the State of Oregon.
4. That the original instrument has been ( ) lost, ( ) destroyed or ( ) stolen and has not
been entered into our records.
5. That I furnish this statement to authorize the Dept of Administrative Services of the
State of Oregon the cancellation of the original instrument once two years have
passed from the date of issue.
6. I have the authority to approve the expense that may be created in the event the
cancelled warrant is cashed.
7. My agency accepts the responsibility of this cancelled warrant and will work toward
reimbursement from this payee in the event the original is cashed.
Agency Name ___________________________________
Signed _________________________________________
(Accounting Manager)
Title ___________________________________________
Date ___________________________________________
Please submit this form to WarrantStopCancel.1.SFMS@oregon.gov
Revised: 7/13/2021