AFFIDAVIT AND AGREEMENT

FOR ISSUANCE OF DUPLICATE WARRANT

STATE OF       Nebraska

COUNTY OF cass

I, Angela R. Payton of      2122 Lincoln Ave Plattsmouth, NE 68048

County of cass , State of Nebraska being duly sworn, depose and say that a warrant

of the State of Iowa, number 04561331 account number       0001-10-625-2007-2840

in the amount of $ 584.00 and dated   May 26, 2010 drawn to my order not been

received by me.

In consideration of the issuance and delivery of a new or duplicate warrant in like amount I hereby
agree that I will surrender the warrant first described above should such warrant ever come into my
possession.

Signature of Payee angela payton

Co-payee Signature (if more than one payee)      

INSTRUCTIONS CONCERNING DUPLICATE WARRANTS.

To better protect his/hers interest, the owner of a warrant should immediately notify the
department for whom they preformed the service/delivered goods, in writing of a lost warrant. The
notification should describe the circumstances of the loss and give, if possible, the warrant issue date,
number, and amount. Request for stop payment should also be made.

THIS MAY BE FAXED TO (515)281-3906 INSTEAD OF MAILED