011619 DUPLICATE WARRANTS 23.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: January 2, 2019 9-
To: Clerk of the Board
From: Kathy Baskom
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 506-0572 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: Fund 219 Dept 190 County Attorney

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 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
Dade 2 of this form.
Hayden Mills (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 22-Jan-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 beAissued to him/her in the sum of $ 691.98 .(3 )
Signed: V\ (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 er2o1120- 20 I
I
NOTARY PUBLIC
MONICA S. TORRES-BROWN
My commission expires: t.) Notary Public - Arizona
, `r. - -4 • Maricopa Expires 01/18/2022 County (seal)
Warrant/Check Number 000000380015316
(if known) (6)
Original Date of Issue 22-Jan-2018
(if known) (7)
Reason for original issue of Warrant/Check (8):
0 Payroll
CLERK, BOARD OF SUPERVISORS
0 For Services or Goods furnished MARICOPA COUNTY
0 Treasurer's refund/payment
Other: Victim Compensation Check: Reissue
(D04_1) wle) \1*2:3elpi \)C..01-1 00022L-1 (1,s,+