STALE AZ DEPT OF ECONOMIC SECURITY.PDF

1-7114 I" r 14 _OF 1 .
MARICOPA COUNTY [IA
Department of Finance
2111
301 West Jefferson, Ste 960 12: 3 f
Phoenix, Arizona 85003 ti(44
02,\IIktA
INTEROFFICE MEMORANDUM
Date: October 9, 2019
To: Clerk of the Board
From: Maria Meza
Department of Finance
Subject: Affidavit — Stale Dated Treasurer Warrants
Please find attached Affidavit to be included on the next available Board Agenda.
• The attached item/s have been researched to ensure the warrant in
question has not been cashed or previously re-issued.
• The original warrant has a void/stale date/stop payment done.
Please return the approved Affidavit to my attention Department of Finance, Suite 960.
If you have any questions you may contact me at 602-506-1336 or
maria.meza@maricopa.gov
Thank you.
Re: Treasurer Warrants
W#877114 06/19/18 $243.34
W#866519 12/07/17 $64.27
W#867639 12/07/17 $22.82
RE:DES Child Support Payments
Fund:100 AP11 BSA:2010

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate or 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.
Arizona Department of Economic Security (1) being first sworn, upon oath deposes and says:
Name/Claimant „ ,
On or about See (mei: 13e/bvu (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 $ 330 - 43 .(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
(5) Subscribed and sworn to before me this 02 day of 20/9 .
OTARY PUBLIC
SHANNON RENTERIA
Notary Public - State of Arizona
My commission expires: MARICOPA COUNTY
2tity14€ 621 taeleal My Commission August 27, 2021 Explres (seal)
Warrant/Check Number
(if known) (6)
Original Date of Issue
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
LI For Services or Goods furnished
El Treasurer's refund/payment
Other: Oct- Nov 2017 & Feb- May 2018 Citing Agency payment-AZ Revised statue 12-116.04

DEPARTMENT OF ECONOMIC SECURITY
Your Partner For A Stronger Arizona
Douglas A. Ducey Michael Trailor
Governor Director
September 26, 2019
To Whom It May Concern;
John Sours, Accounting and Budget Manager with Department of Economic Security
Division of Child Services, is signing the stale-dated affidavit on behalf of the Department of
Economic Security to re-issue stale-dated checks in the amount of $330.43. The checks were
issued to the Department from the Maricopa County Treasurer and were not deposited timely
into a fund and have since expired.
Check Number Dated Amount
877114 6/29/18 $243.34
866519 12/07/17 $64.27
867639 12/07/17 $22.82
Thank you,
John Sours
Budget & Accounting Manager
Division of Child Support Services
Arizona Department of Economic Security
602-542-4512
JSours@azdes.gov
1789 W. Jefferson, MD7217, Phoenix, AZ 85007, Phoenix, AZ 85007
Telephone (602) 542-4500 • Fax (602) 542-4727 • www.azdes.gov