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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: April 17, 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: ADELA GARFIELD Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: gr Duplicate or E.:1 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 Daae 2 of this form. Adele Garfield (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 17-Oct-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 $ 11 2.75 .(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 day of /9/47 / 20 /9 . NOTARY PUBLIC CODY JIM SMITH 4 Wiry Pubbc - Arizona My corypission expires: 4 My Corm. Marlow Expirss County May 10,2019 /My /0 t->/ (seal) Warrant/Check Number 3010018466 (if known) (6) Original Date of Issue 17-Oct-2018 to (if known) (7) 30120iS DATE_ APR 1 7 2019 Reason for original issue of Warrant/Check (8): Payroll MARICOPA COUNTY LI For Services or Goods furnished Li Treasurer's refund/payment Other: Victim Compensation: VC2017000328-2 -1-€1) 64 -I 6a)(41) (0 ivo arc, 36, Igo COUNTY EXPENSE WARRANT TREASURER OF MARICOPA COUNTY WARRANT NUMBER PHOENIX, ARIZONA 3010018466 DATE 10-30 -2018 91-2/1221 JPMorgan Chase Bank N.A Phoenix, AZ One Hundred Twelve And 75/100 Dollars $112.75 PAY TO THE ORDER OF AMOUNT Adela Garfield 301 W Jefferson 9th Floor Void After PHOENIX AZ 85003 365 Days For Questions - 602-506-1379 or email AP@MAIL.MARICOPA.GOV NOT NEGOTIABLE MARICOPA COUNTY DEPARTMENT OF FINANCE RETAIN THIS FOR PAYEE WARRANT NO. WARRANT DATE WARRANT AMOUNT YOUR RECORDS VICTIM WITNESS 3010018466 10/30/2018 $112.75 INVOICE NUMBER DESCRIPTION PURCHASE ORDER NO. VOUCHER NO. AMOUNT 00000049794K VC2017000328-2-rqst7 GAX1D D190 190000014764 112.75 190000014764