STALE SECRETARY OF STATE .PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: August 16, 2019
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
Please find attached affidavit for lost 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 506-1329 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: SECRETARY OF STATE
Dept. 210, Fund 248

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or 0 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
bade 2 of this form.
SECRETARY OF STATE (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 17-Aug-2018 (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 $ 89,940.62 .(3)
Signed: '1/1411--t (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) Subscribeicli and sworn to before me this day of A°1 20 11 .
NOTARY PUBLIC
My FomIsion expires:
0--) I p s a-69-0 (seal)
Warrant/Check Number 3010012930
(if known) (6)
Original Date of Issue 17-Aug-2018
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
LI For Services or Goods furnished
El Treasurer's refund/payment
Other: Revertment of HAVH GY10, HAVP GY11 & HAVA GY07 funds

KATIE HOBBS
SECRETARY OF STATE
State of Arizona
May 17, 2019
Maricopa County Department of Finance
Attn: Beth Brown
301 West Jefferson Street, Suite 960
Phoenix, Arizona 85003
To Whom It May Concern:
The Secretary of State's Office designates Sarah Schnupp, Chief Financial Officer, as the
authorized signer for our agency in regards to any and all financial matters.
If you have any questions, please feel free to contact me.
Sincerely,
XtGe,r-dpiu,a--
Allie Bones
Assistant Secretary of State
Arizona Secretary of State Katie Hobbs
abones@azsos.gov
602.542.4919
1700 West Washington Street, Floor 7
Phoenix, Arizona 85007-2808
Telephone (602) 542-4285 Fax (602) 542-1575
www.azsos.gov