Page 48

Check Handling Information APPENDIX I and Procedures 10/19 Page 15

AFFIDAVIT ON CHECK ENDORSEMENT

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

PURPOSE OF FORM - This is three-part form which includes sections for the Affidavit on Check Endorsement, Lost or Stolen Check Report and the Bank of America form. These forms are to be completed when requesting a stop payment. The form should be completed by the payee (as much as possible) to allow the Fraud Investigator to compare the handwriting on the form to the payee’s signature.

USE OF FORM - To be used by the local social services agency when a check is reported lost or stolen to secure the payee’s statement that he or she did not endorse the check.

NUMBER OF COPIES - Three original signed affidavits.

DISPOSITION - Submit two original signed affidavits (which will include the Lost Check Report or Stolen Check Report) to the VDSS Home Office, Division of Finance, Fiscal Processing Unit (FPU). File the third original signed affidavit (which will include the Lost Check Report or Stolen Check Report in the eligibility record). Additionally, when a copy of the police report is provided for a Stolen Check Report, file the report in the eligibility record and give a copy to fraud unit in the local agency upon request.

INSTRUCTIONS FOR PREPARATION OF AFFIDAVIT ON CHECK ENDORSEMENT

Locality

Locality that listed check on warrant register

Category

Type of check issued

VaCMS Case No.

Complete case number

Worker Name and #

Complete worker’s name and number

Check No.

Complete 8-digit check (warrant) number

Dated

Show date on the check

$

Entire amount of the check, including cents

Payable to

Payee name

Signature

Only PAYEE signature

Date

Date the affidavits are signed

SSN

Payee’s social security number

Address

Address as shown on the warrant register.

Must have City, State and Zip

Notary Blanks must be completed with Notary information, signed by Notary, and imprinted with the Notary seal.

TANF Transmittal 67