Affidavit and Agreement
For Reissuance of Warrant
tax.iowa.gov
06-191 (8/1/2023)
You must wait a minimum of 14 days from the issue date of the original warrant/check before submitting a
request. You must return this form, original warrant (if available), AND the required documentation listed
below. Following our receipt of this information, allow 6 - 8 weeks to receive the replacement warrant or
longer if all the required documents are not submitted.
Reason for Request:
☐ Original warrant was not received ☐ Original warrant is lost or stolen
☐ Original warrant was destroyed or damaged ☐ Original warrant needs name correction
☐ Original warrant is outdated (more than 6 months from the original warrant date)
☐ Taxpayer Deceased (Please submit a copy of the death certificate AND IRS Form 1310 with any
required documentation)
Required Documentation:
Individuals:
• Copy of current driver’s license or state-issued photo ID
• Proof of current mailing address
• Signed Request for Warrant Cancellation Form
(Please skip Sections 1 and 2, complete ONLY Section 4 of
the Request for Warrant Cancellation Form.)
Businesses:
• Proof of federal ID number. (Ex. Any official state or federal government document showing the business name
and federal employer identification number.)
• Proof of current mailing address
• Signed Request for Warrant Cancellation Form.
(Please skip Sections 1 and 2, complete ONLY Section 4 of
the Request for Warrant Cancellation Form.)
Warrant number: _________________ Dated: _________________ Amount: ____________________
Payee name(s): _________________________ SSN or Tax ID number: _________________________
Address: _______________________________ City: ________________________________________
State: ______________ ZIP: ______________ If this is a permanent address, change check this box. ☐
Phone: ________________________________ Email: _______________________________________
I request the original warrant to be stopped and a replacement warrant issued. Should the original warrant
come into my possession, I will not attempt to cash it and will return it immediately. Neither I nor anyone
on my behalf has deposited or cashed this check.
I, the undersigned, declare under penalties of perjury or false certificate, that I have examined this
affidavit, and, to the best of my knowledge and belief, it is true, correct, and complete.
Signature of Payee (or Authorized Agent): _________________________________ Date: ___________
Signature of Co-Payee (if applicable): ____________________________________ Date: ___________
Mailing and Contact Information:
Fax: 515-281-5830
Email: IDREFT@iowa.gov
Phone: 800-367-3388 or 515-281-3114
Mail: Iowa Department of Revenue
Attn: Internal Services – Accounting
PO Box 10460
Des Moines, IA 50306-0460
Department of Administrative Services - State Accounting Enterprise
REQWC07
REQUEST FOR WARRANT CANCELLATION
SECTION 1 - Required - Warrant Information - To be Completed by Issuing Department Only
If an incorrect vendor name was previously entered, a warrant will not be issued.
Dept No.
Warrant No.
I/3 Document ID
Issue Date
Amount
Payable to:
Optional Routing/DBA:
Street Address:
City: State: Zip:
Issue New Warrant: No Yes - Explanation:
Dept Contact: Phone: Request Date:
Additional Dept Info:
SECTION 2 - Warrant Is Attached - To be Completed by Issuing Department Only
Cancel Warrant/Original Is Attached Procedure 270.550
Complete Section 1, attach warrant to this document, then mail to issuing department.
Issuing department sends finalized document to internal office or State Accounting Enterprise.
SECTION 3 - Warrant Not Attached - To be Completed by Issuing Department Only
Cancel Warrant/Original Not Attached Procedure 270.550
Issuing department completes Section 1, then sends this document to Payee for signature.
Payee must return signed document to issuing department for processing.
Issuing department sends finalized document to internal office or State Accounting Enterprise.
To prevent future warrant cancellations, consider issuing an EFT.
SECTION 4 - Payee Certification - To be Completed by Payee and Returned to Issuing Department
I, the Payee, certify that:
• I have not received the State of Iowa warrant above, which was made in my name and I have no knowledge of its
whereabouts; or
• I received the warrant above, but it has been lost, damaged, or destroyed before I could redeem it.
In consideration of cancelling the above warrant, I agree to promptly surrender the original warrant (described above)
if it ever returns to my possession or control to the issuing department.
I certify under penalty of perjury, and pursuant to the laws of the State of Iowa, that this statement is true
and correct.
Handwritten Signature of Payee Printed Name of Payee Date
