PALOMAR COMMUNITY COLLEGE DISTRICT

COUNTY of SAN DIEGO, STATE of CALIFORNIA

1140 West Mission Road

San Marcos, CA. 92069-1487

 

AFFIDAVIT TO OBTAIN DUPLICATE OF LOST OR DESTROYED WARRANT

 

1)             STATE OF CALIFORNIA  )

                COUNTY OF SAN DIEGO  )                                               SS

 

Deposes and says:

 

That he/she, PAYEE is the legal owner of that Certain District Warrant numbered                       ,

Dated                   and drawn by the County Auditor of the County of San Diego the Palomar Community College District Fund and said county, in favor of                                       as PAYEE thereof, for                                                                                                            Dollars.

 

That said warrant was not endorsed, has not been paid but was lost, destroyed, or mutilated before the same was paid by the County Treasurer of said County of San Diego, and cannot now be produced by the said payee.

 

2)                   That the circumstances of such loss, destruction, or mutilation and all material facts relative thereto, are as follows:  (STATE REASON)

 

 

 

 

I agree to repay the County of San Diego the amount of this duplicate warrant plus interest and reasonable collection expenses if my actions have caused the County of San Diego to issue this duplicate warrant and it is not owed to me.

 

 

I CERTIFY (OR DECLARE); UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT.

 

DATED:                                             AT:                                                                     ,                                                                                                                                                

 

3)                   SIGNATURE:                                                                               .

                                                 Form 124 (Gov. Code 29850-29854 – CCP 2015.5)                                                                                           

 

FOR AUDITORS USE ONLY

 

 

THE ORIGINAL WARRANT IS NOT IN THE FILE OF REDEEMED WARRANTS IN THIS OFFICE AS OF                                   . THE ORIGINAL WARRANT WAS PAID ON                         .

 

 

WILLIAM J. KELLY

CFO/AUDITOR AND CONTROLLER

 

BY:                                                         ;                   DATED:                                     ;

 

@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@@

District re-issue of warrant, on                                 ; by                                               ;

Warrant #                                                      Voucher #                             .  

Authorized by ­­_______________________