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Check Handling Information APPENDIX I and Procedures 10/18 Page 11 Department of Social Services

Affidavit on Check Endorsement

Locality: ____________________ VaCMS Case No: ________________________________

Category: ____________________ Worker Name/ No.: _______________________________

I hereby state that the Commonwealth of Virginia, Department of Social Services Assistance Check No.__________, dated_________________, in the amount of $___________, made payable to me, ____________________________, by the Treasurer of Virginia, was not endorsed by me. I also state that I did not authorize any other person to endorse my name thereon. I further state that I have not received payment or payment of the said check directly or indirectly in any way, shape or manner, nor authorized anyone to receive payment of the said check.

I understand and agree to notify and return to the Department of Social Services the original check in the event I receive it after signing this statement.

I agree by signing this affidavit, to cooperate with the Department of Social Services and any law enforcement agencies in the investigation and/or prosecution of any person(s) who may be responsible. If I am reporting the said check stolen, I agree to file a police report and provide a copy of the report, or the report number, within 45 days of the original check issuance to the Department of Social Services in order to receive a replacement check.

I have read the above statement, or it has been read to me, and I state this information is true and correct. I understand that making a false sworn statement is subject to federal and/or state statutes and may be punishable by fines and/or imprisonment. ______________________________________________ ___________________

Signature of Payee/Client

Date

SSN: ________________________ Address: _______________________________________ _________________________________________________________________________________ Subscribed and sworn to me, a Notary Public for the City/County of ___________________________in the State of Virginia, this _______ day of_____________, 20_____. My commission expires_____________, 20____. ____________________________________ Notary Public

032-06-0118-11-eng (10/18)