INV-19

STATE OF

)

AFFIDAVIT AND

COUNTY OF

)

INDEMNITY BOND

, being first duly sworn, deposes and says that

warrant(s) numbered

for

dollars, dated

,

allegedly issued by

, an agency of the State

of North Carolina and drawn on the State Treasurer, and allegedly made payable to the order of this affiant

has/have not been received by this affiant,

has/have been received by this affiant but has/have since been stolen or lost,

has/have been received by this affiant, but has/have since been destroyed,

has/have been examined by me and the first endorsement is not mine

that I did not cash the warrant(s) and have never benefited in any manner from said warrant(s);  that this affiant

seeks to have the State of North Carolina replace said warrant(s) and,

In Consideration of the issuance of the replacement warrant(s) by the State of North Carolina,

I the undersigned, am held and firmly bound unto the State of North Carolina in the sum of

dollars (an amount equal to the sum of the warrant(s) involved herein), to be paid to the State of North Carolina,

to the payment wherof, well and truly to be made, I bind myself and each of my heirs, executors and

administrators, firmly by these presents, so that if I, my heirs, executors or administrators, shall at all times

save hormless and keep indemnified the State of North Carolina against any claim, demand, loss or expense

of any character, and against all loss and damages whatever that shall or may result at any time to the State of

North Carolina, or any agency therof, arising out of and by reason of the issuance to the undersigned of the

duplicate warrant(s) in replacement of the warrant(s) herinabove described, then this obligation to be void and of

no effect, otherwise to be and remain in full force and effect.

WITNESS my hand and seal, this

day of

,

(SEAL)

Social Security Number

Affiant

Subscribed and sworn to before me

This   the

day of

,

.

Notary Public

My commission expires:

The statute of limitation for endorsement forgeries is three years. (G.S. 25-4-111)