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MARICOPA COUNTY SOR's
Department of Finance
name es
301 West Jefferson, Ste 960 WeLBAY -7 PH 4: 05
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: May 7, 2021
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Notice of Claim
Please find attached Affidavit for stale dated warrant to be included on the next
available Board Agenda.
e The attached item has been researched to ensure that warrant in question
has not been cashed or previously re-issued.
e The original warrant has a void/stale date/stop payment done.
Please call me at 506-1329 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: DAVID HICKMAN JR
Dept. 750
Fund 675
Application for a Duplicate or Stale-Dated Warrant/ Check
Affidavit/ Claim Form
This application is for: Duplicate or CJ stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARICOPA numbers on the Instruction sheet which is
paqe 2 of this form.
DAVID HICKMAN JR (1), being first sworn, upon oath deposes and says:
On or about 30-Dec-2020 (date)(2) a warrant/check was issued to the
above named person/entity in the amount as stated below. Such warrant/check was
either never received or was subsequently inadvertently lost or destroyed and there is
no reasonable probability of its being found or presented for payment, or it was not
presented for payment within one year after the date of issuance.
Therefore, under penalty of perjury, claimant hereby affirms that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement
warrant/check be issued to him/her in the sum of $ 1,821.55 (3)
sent
(4)
Note. Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
ial
(5) Subscribed and sworn to before me this _. { day of Wiuw 20-2/ .
a — ; C/ yr qublitiiay,
Gazer ~*~ ) sor ROD A/a My,
NOTARY i ae an PELE. |
My commission expires:
O?- 2132 RZ
Warrant/Check arran Numb 4, “Hiniw +79
i oun) (6) (3010078221
Original Date of Issue
30-Dec-2020
(if known) (7)
05/10/2021
Reason for original issue of Warrant/Check (8):
QO Payroll
O For Services or Goods furnished
C Treasurer's refund/payment
Other: Worker compensation payment