AZ DEPT. OF ECONOMIC STALE DATED.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
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INTEROFFICE MEMORANDUM
Date: April 17, 2019
To: Clerk of the Board
From: Nadine Higuera
Department of Finance
Subject: Affidavits - Replacement of Lost or Stale-dated Warrant
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 506-1354 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: : Arizona Department of Economic Security

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: El Duplicate or n 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 (J.) being first sworn, upon oath deposes and says:
Name/Claimant
On or about 31-May-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 $242.40 .(3)
Signed: (4)
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was aiginally issued.
(5) Subscribed and sworn to before me this day of 20 .
&tr/dri
z r/G4
SHANNON RENTERIA
Notary Pubic- State olAtizone
My commission expires: MARICOPACouNTY
My Commission Expires
August 27, 2021 (seal)
Warrant/Check Number (SEE ATTACHED
(if known) (6)
Original Date of Issue 31-May-2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
O For Services or Goods furnished
O Treasurer's refund/payment
')k Other: MAY 2017 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
To Whom It May Concern:
Kori Kappes, Senior Managing Analyst with Department of Economic Security is signing the stale-dated
affidavit on behalf of the Department of Economic Security to re-issue stale-dated checks in the amount of
$242.40. 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
858069 5/31/2017 $ 45.60
861711 7/27/2017 $ 90.46
861227 7/17/2017 $ 26.60
865117 10/30/2017 $ 22.78
868658 1/30/2018 $ 30.36
869927 2/27/2018 $ 26.60
$ 242.40
Thank You,
\hp„plosic,
Kori IKappes
602-364-0825
kkappes@azdes.gov
1789 W. Jefferson, Mail Drop 1111, Phoenix, AZ 85007 • P.O. Box 6123, Phoenix, AZ 85005
Telephone (602) 542-5757 • Fax (602) 542-5339 • www.azdes.gov