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00-953
(Rev.7-09/3)

AFFIDAVIT AND INDEMNITY AGREEMENT FOR LOST WARRANT

I _________________________ , _____________________________ , (hereinafter (“indemnitor”) the

(NAME) (ENTITY AND TITLE)
undersigned, being of sound mind and over the age of 18, capable of making this affidavit and indemnity
agreement, duly sworn, state that Indemnitor is the lawful owner of warrant number _________________
issued by the Texas Comptroller of Public Accounts for the sum of $ __________ . Indemnitor further states
that:

1. it/he/she is not in possession of the warrant now;

2. it/he/she was entitled to enforce the warrant when the loss of possession occurred;
3. the loss of possession was not the result of a transfer by it/him/her;
4. the loss of possession was not the result of a lawful seizure; and
5. it/he/she cannot reasonably obtain possession of the warrant because the warrant was destroyed,
the warrant’s whereabouts cannot be determined, or the warrant is in the wrongful possession of an
unknown person or a person that cannot be found or is not amenable to service of process.

(Optional) The warrant is made payable to _________________________ , or order, which is now the
(PAYEE)
property of Indemnitor; and that said warrant is now lost and cannot be produced by Indemnitor.

NOW, THEREFORE, in consideration of the payment of said warrant to Indemnitor of the sum of
$ _____________ , Indemnitor does promise to truly indemnify, defend and protect the State of Texas from
any loss or harm occasioned or sustained by the State of account of payment of the above-described warrant
to Indemnitor. THIS AGREEMENT SHALL BE INTERPRETED ACCORDING TO THE LAWS OF THE STATE
OF TEXAS.

INDEMNITOR

Entity: ___________________________________

By: ______________________________________

Title: ____________________________________

STATE OF __________________

COUNTY OF ________________

Before me, the undersigned Notary Public for the State of _________________________ , appeared
________________________ , _____________________________ , who after being duly sworn, did
(NAME) (TITLE AND COMPANY)
acknowledge and sign the foregoing AFFIDAVIT AND INDEMNITY AGREEMENT FOR LOST WARRANT.

SWORN AND SUBSCRIBED this _______ day of _____________ , _____ .

________________________________________

Notary Public, State of _______________________

My Commission expires _______________ , _____