011619 DUPLICATE WARRANTS 14.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: December 18, 2018
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Replacement of Lost — Stale dated 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: CHAANCE W JOHNSON

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: LI Duplicate or 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
Dade 2 of this form.
Chaance W. Johnson (1) :1)11
Name/Claimant
On or about 26-Mar-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/chec hiryi/her in the sum of $ 66.64 .(3)
Signed: (4)
Note: PleasOttach 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 l7Th? day of _,torni/ 20 (b .
NOTARY PUBLIC :----
JOLIE M. PANYON
My commission expires: Notaiy MARICOPA Public - Stale COUNTY of Arizona
V't. 201 My Commission March 9, 2019 Expires (seal)
Warrant/Check Number 000003010001681
(if known) (6)
Original Date of Issue 26-Mar-2018
(if known) (7)
Reason for original issue of Warrant/Check (8):
E Payroll
For Services or Goods furnished
El Treasurer's refund/payment
Other: Stale dated check - Victim Compensation - VC2017000440-1 2.
Cc1.114-1) 3255t 00 0 roN6 31°i