REQUEST FOR WARRANT CANCELLATION A warrant cancellation request cannot be processed unless this form is completed to the fullest extent possible, signed, and returned to the address listed at the bottom. Instructions are provided on page 2. Member Data OAG Case Number: _____________________________ Non-Custodial Parent's Name: ________________________________________ Custodial Parent's Name: ____________________________________________ Custodial Parent's SSN: __________________________ Warrant Being Cancelled Payee: ________________________________________ Mailed to: ______________________________________________________________________ Individual/Entity Requesting Warrant Cancellation and Replacement Name or Business/Entity Title: __________________________________ Current Address: ______________________________________________________________________ Telephone Number: ___________________________________ Address Change Needed: Yes No Reason for Warrant Cancellation and Replacement: __________________________________________________________ I, __________________________, certify that I have not negotiated (cashed or deposited) and will not negotiate the following warrant(s): Warrant Number Issue Date Warrant Amount By signing this form, I am agreeing that: · To my knowledge, the above referenced warrant was either lost, damaged, or destroyed. · If the warrant was damaged and I have any portion of it, I will return it with this form to the address provided at the bottom of this letter. · If I receive this warrant in the future, I will return it to the address below and will indicate that the warrant is being returned because it was cancelled and a replacement warrant was reissued. A stop payment will be placed on the original warrant when this form is received. If I later cash the original warrant, I will be responsible for any loss to a merchant, a check cashing entity, or a government agency. I hereby agree that the state may recover the amount of the loss for honoring payment of the original warrant from child support collections that would otherwise be sent to me. Signature of Requesting Party: ________________________________________ After signing this form, please return it to the address below: Texas Child Support Disbursement Unit P.O. Box 659730 San Antonio, TX 78265-9730 FAX: (210) 921-2394 November 2014 Form 1760 American LegalNet, Inc. www.FormsWorkFlow.com Date: ____________________ INSTRUCTIONS FOR COMPLETING THE WARRANT CANCELLATION REQUEST FORM 1. Complete all of the relevant lines of data on the upper portion of this form. If you are a(n): · CP, you are not required to complete the "Business/Entity Title" line · NCP, you are not required to complete the: o "Business/Entity Title" line or o "Custodial Parent's SSN" line · third party warrant recipient (someone other than the CP or NCP), you are not required to complete the: o "Non-Custodial Parent's Name" line o "Custodial Parent's Name" line o "Custodial Parent's SSN" line 2. Complete the lines provided on the lower portion of the form, being sure to specify: · your full name (Print Name) · the warrant number(s) being cancelled · the issue date of the warrant(s) being cancelled · the amount of the warrant(s) being cancelled Note: To obtain warrant information (such as the warrant number, amount, or issue date), you can call 1800-252-8014. 3. Sign the form on the "Signature of Requesting Party" line and enter the current date on the "Date" line. 4. Mail or fax this form to the address provided below. Texas Child Support Disbursement Unit P.O. Box 659730 San Antonio, TX 78265-9730 FAX: (210) 921-2394 November 2014 Form 1760 American LegalNet, Inc. www.FormsWorkFlow.com