121218 STALE DATED WARRANTS 1.PDF

MARICOPA COUNTY ,urt
Department of Finance
301 West Jefferson, Ste 960 1011 NOY 20 Ati 10: 28
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: November 20, 2018
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Replacement of 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: RANGEL RAQUEL

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
page 2 of this form.
RANGEL RAQUEL (1), being first sworn, upon oath deposes and says:
Name/ anent
On or about 24-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
warrant/chcicbe issued to prtm/heOkthe sum of $_303 - 83 .(3)
Ilda "ft (4)
Note: Please littach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) Subscribed an worn to before me this LIM day of NOVI m ber 20 I B •
Notary VERONICA Public, State REYES of Arizona
My commission expires: My Commission MaricopeCounty Expires
"K 2-0 2,0 January28, 2020 (seal)
Warrant/Check Number 855290
(if known) (6)
Original Date of Issue 24-Apr-2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
▪ Payroll
▪ For Services or Goods furnished
Treasurer's refund/payment REFUND SLIP ID:201700334
LI Other: