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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: November 16, 2018 To: Clerk of the Board From: Marcia J. Clark Department of Finance Subject: Affidavit — Replacement of Lost Warrant (I; Please find attached 1 Affidavit for stale dated warrant 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 warrant is lost. Please call me at 506-1379 if you have any questions. Please return the approved Affidavits to my attention in the Department of Finance, Suite 960. Thank you. Re: FUND 219- D190 - COUNTY ATTORNEY - MVICTIM INTERFACE Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: iv Duplicate or D 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 oaoe 2 of this form. Clinton School District #32 (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 02-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 be issued to h m/her in the sum of $ 125.00 .( 3 ) Signed: (1 [4 rishiitt/t (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 it i,-',,t ,,q ke ,' 20 AtA -• 70. 72/g NOTARY PUBLIC 1..k.t.EN 7 THOMAS ALLEN STACK JR ,01AR,,,, I, -f- NOTARY PUBLIC for the . My commission expires: v — ' ,. State of Montane SEAL `r Residing at Clinton, Ai My Commission Expinfeeel) July 23, 2020. Warrant/Check Number 000000380013833 (if known) (6) Original Date of Issue 02-Jan-2018 (if known) (7) Reason for original issue of Warrant/Check (8): El Payroll El For Services or Goods furnished El Treasurer's refund/payment Other: Victim Compensation Porgram VC2017000552-1 cE r NOV 16 2018 BY:— —