Agency Name

Enter the name of the agency that issued the warrant.

Agency Code

Enter your three-digit agency code.

If this is a payroll warrant, the agency code should be 142.

Contact Name

The person to contact for questions regarding the cancellation.

Phone #

Phone number of the contact person.

Date

Current date.

Normal Cancellation

Mark this box if you have the warrant to attach to the form.  Otherwise, leave blank. 

If this is a payroll warrant, use the Payroll Cancellation box instead.

Lost Cancellation

Mark this box if you are processing a Lost Cancellation and attach a completed Certification for Cancellation form. Otherwise, leave blank.

If this is a payroll warrant, use agency 142 and the Lost Payroll Cancellation box instead.

Payroll Cancellation

Normally only used by the State Controller’s Office Division of Statewide Payroll for Manual voids.

lOST PAYROLL CANCELLATION

Mark this box if you are processing a Lost Payroll Cancellation and attach a completed Certification for Cancellation form. Otherwise, leave blank. 

Send these to the State Controller’s Office Division of Statewide Payroll.

Forgery Cancellation

Mark this box if you are processing a Forgery Cancellation and attach a completed Forgery Affidavit form​. Otherwise, leave blank. 

If this is a payroll warrant, use agency 142.

EFT Cancellation

For SCO use only.

Miscellaneous Cancellation

Mark this box if you have a memo to attach.  Otherwise, leave blank. The agency’s Fiscal Officer or Department Head must write a memo on agency letterhead addressed to the State Controller’s Office, Division of Statewide Accounting explaining the reason for the cancellation and a description of why the Certification for Cancellation of a Warrant is not appropriate

DOCUMENT NUMBER

Enter the document number you used to issue the warrant, if readily available.

warrant number

Enter the nine-digit warrant number of each warrant you are canceling.

amount

Enter the amount of each warrant you are cancelling.

TOTAL

Enter the total of all warrants you are submitting for cancellation.

REASON FOR CANCELLATION

Enter the reason for cancellation.

date cancelled

Leave blank.  SCO will enter this date when they cancel the warrant.

Cancelled by

Leave blank.  SCO will enter this information when they cancel the warrant.