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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: November 19, 2019 To: Clerk of the Board From: Walter Chang Department of Finance Subject: Affidavits — Replacement of Lost Warrants Please find attached 1 Affidavits for lost warrants to be included on the next available Board Agenda. • The attached items have been researched to ensure the warrant in question have not been cashed or previously re-issued. • The original warrants have a void/stale date/stop payment done. Please call me at 506 - 8747 if you have any questions. Please return the approved Affidavits to my attention in the Department of Finance, Suite 960. Thank you. RECEIVED-0: 61" NOV 1 9 2019 Re: Fund: 675 / Dept: 750 / Risk Mgmt / Company: David Crissinge MARICOP,6, COUNTY CLERK BOARD OF SUPERVISORS Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or El 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 Page 2 of this form. DAVID CRISSINGER (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 22-0ct-2019 (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 bejs4ued to him/her in the sum of $ 1,399.02 .(3) Signed: (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. day of NIN 204. OFFICIAL SEAL 11 K. FULGHUM j g Notary Public - State of Arizona DA7,1° MARICOPA COUNTY I ° My . I• I • Comm. I •• II•••.=•• Expires I •• Aug. III • I•••• 2, I 2021 •• I•• ! (seal) Warrant/Check Number 3010045778 (if known) (6) Original Date of Issue 22-Oct-2019 (if known) (7) A P P C; Reason for original issue of Warrant/Check (8): DATE NOV 2 1 2019 CI Payroll CI For Services or Goods furnished 111 Treasurer's refund/payment Other: settlement check for DAVID CRISSINGER