01.30.19 REPLACEMENT WARRANT ATTACHMENT.PDF

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
oarle 2 of this form.
GABINO FLORES SANCHEZ (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 05-Apr-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
warranticheckrbe issuediTo hill/her in the sum of $ 23,92 .(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 I ),,) day of r_k' ( ' 11 )t' , 20 i.
NOTARY PUBLIC
AMANDA RODRIGUEZ
Notitry Pub3c Stae Atizom
My commission expires: MARICOPA COUNTY
11,4' My August Corarni$5ion 19, 2020 ExpjFes seal)
3 —
Warrant/Check Number 000000370000810
(if known) (6)
Original Date of Issue 05-Apr-2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
• Payroll
E For Services or Goods furnished
E Treasurer's refund/payment
Other: Stale dated check - Victim Compensation - VC2015000554-1
2:45 -6 61"-0 FON° 41`'t

Automated Disbursement(AD) Page 1 of 1
Automated Disbursement(AD) Dept: D180 ID: WAR000000800 Ver.: 1 Function: New Phase: Final
Modified by batchadm , 07/20/2016
I Header
General Info Consolidation Object Payee Cancellation Additional Amounts Document information
Document Name: Bank Account: Stub Detail Line Count:
..-, 1000 1
Check/EFT Number: Check Exported For Printing:
Record Date:_ . 000000370000810
07120/2018 ) —R-Orbligwiff Number:
Buci_g.ef--Ffr-
--rS Z: Transit Routing Number:
Fiscal Year:
2017. - ChecklEFT Amount:
$23.92
Period:
Check/EFT Issue Date:
07/20/2016
Print Status Indicator:
Printed
Disbursement Category:
Internal Reconciliation:
N/A
Run ID:
15048
Check Printed Date:
blips : //azdom. ho stams. c om :1443/web app/PRDFIN1X1/adv ant ag e/Advantag e/document_... 12/19/2018

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
pape 2 of this form.
MARIELA PATIN° (1), being first sworn, upon oath deposes and says:
Narne/Ulairnant
On or about 01-Jan-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 $ 96.12 .(3)
op,
Signed: .61 To-1)110 (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 Cti day of 1 ckfularks5 20
NOTARY PUBLIC
A DA:RODRIGUEZ
. - State of kizona
My commission expires: couNrif
PttAS 19 i My August Cr;rrrilission 19, 2020 Expires (seal)
Warrant/Check Number 000000370015101
(if known) (6)
Original Date of Issue 01-Jan-2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
D Payroll
D For Services or Goods furnished
DI Treasurer's refund/payment
Other: Stale dated check - Victim Compensation - VC2016000352-1

DATE
01-23-2017 91-2/1221
JP11/lorgan Chase Bank NA
Phoenix, AZ
Ninety Six And 121100 Dollars
$96.12
PAY TO THE ORDER OF AMOUNT
MARIELA PATINO
301 W Jefferson 9th Floor Vold After CH A2ftti N
PHOENIX AZ 85233 365 Days
CLERK Of THE 80 4F; II
3?00 15 LC) Lir I: L221000241: Pi ?O tt 3 949 30°
For Questions - 602-506-1379 or email AP@MAILMARICOPA,GOV NOT NEGOTIABLE
MARICOPA COUNTY DEPARTMENT OF FINANCE
RE FAIN THIS FOR PAYEE WARRANT NO. WARRANT DATE WARRANT AMOUNT
YOUR RECORDS
VICTIM WITNESS 000000370015 01 01/23/2017 $96.12
INVOICE NUMBER DESCRIPTION PURCHASE ORDER NO. VOUCHER NO. AMOUNT
,
00000051023C VC2016000352-1-mst2 GAX1D D190 170000027649 96,12 I A
170000027649
,