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MARICOPA COUNTY ),r' 1-1ARICPt, Jo. C012,4 , , Department of Finance 301 West Jefferson, Ste 960 21119 AUG 16 PM 12: 56 Phoenix, Arizona 85003 Aofivj) Dk11;'- INTEROFFICE MEMORANDUM Date: August 16, 2019 To: Clerk of the Board From: Nadine Higuera Department of Finance Subject: Affidavit — Replacement of Lost/Stale-dated Warrant Please find attached an affidavit for lost/stale-dated warrant to be included on the next available Board Agenda. • The attached item has 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 call me at 506-1354 if you have any questions. Please return the approved Affidavit to my attention in the Department of Finance, Suite 960. Thank you. Re: Dale 0. Brandser Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 0 Duplicate or 19 Stale-Dated (definitions are on page 2) STATE OF ARIZONA Note: Numbers on this form correspond to COUNTY OF MAR1COPA numbers on the Instruction sheet which is Dade 2 of this form. DALE 0. BRANDSER (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 27 -Oct-2017 (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 $ 1,193.29 .(3) Signed: ,,,&7e„ee (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) Subs sworn to before me this rc day of LA4,te-(A-a" NOTA a • • Harpreet Singh Notary Public My commission expires: Maricopa County, Arizona My Comm. Expires 11-a1M2 IA Commission No. 5 EMI Warrant/Check Number 865092 (if known) (6) Original Date of Issue 27-Oct-2017 (if known) (7) Reason for original issue of Warrant/Check (8): LI Payroll D For Services or Goods furnished 1111 Treasurer's refund/payment Other: stale dated