11.28.18 REPLACEMENT WARRANT ATTACHMENT.PDF

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 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
I oaae 2 of this form.
/IZtti4 &A1 7; A , being first sworn, upon oath deposes and says:
Name/Claimant
On or about See attachment (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
prc,cented 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 bv*ue,d)to bim/her in the sum of $ See attachment -(3)
Signe
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 06460,-1 20 a
/
N TARY PUBLIC KATHERINE PLUHOWSKY
Notary Public - Arizona
Maricopa County
My commission expires: Comm. Commission Expires # May 544594 27, 2022
5/9 ii/g 6 ,901 seal)
Warrant/Check Number
if known) (6) See attachment
Original Date of Issue
(if known) (7)
Reason for original issue of Warrant/Check (8):
E Payroll
E For Services or Goods furnished
E Treasurer's refund/payment
Other:
ARIZONA CENTRAL CREDIT UNION VICTIM ID 23171

Summary of Unclaimed Funds
Warrant Number Warrant Date Vendor Name Amount
00350031043 06/09/15 ARIZONA CENTRAL CREDIT U $10.00
00350011447 11/10/14 ARIZONA CENTRAL CREDIT U $20.00
00350011446 11/10/14 ARIZONA CENTRAL CREDIT U $100.00
00350031042 06/09/15 ARIZONA CENTRAL CREDIT U $101.00
Total $231.00

•x 116501 Phoenix, AZ 850614650
(602) 264-6421 I 1-866-264-6421
October 18, 2018
To whom it may concern: Maricopa County Treasurer
This document is designating authorization to Michael (Mike) Pillen — Manager at Arizona Central Credit
Union to sign and or receive documents-payments-checks on the behalf of Arizona Central Credit Union-
Entity.
Kathy/Pluhows ,21)( Vice President Financial Resolution

ARIZ-ONA CEYTRAL CREDIT
BOX 11E50
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7 CREDIT Ti
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ARIZO2A CENTRAL
F.0 BOX 11650
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ARIZ ON.P .CRE UN
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APRIL-212'0
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CAJIJILL, kERIL-2: 20.00

HUNDRED ONE DOLLARS AHD
ARIZCJA CENTM CRED - I UN-0
P.0 BOX 11-653
PHOENIX
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•EL', JACOB-112E

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: El Duplicate or El 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_
e-frevilitocZeft (1), being first sworn, upon oath deposes and sa ys:
Name/Claim
On or about See attachment (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 subse quently inadvertentl y lost or destroyed and there is
no reasonable probability of its bein g found or presented for payment, or it was not
presented for pa yment 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 owin g, and the applicant re quests that a replacement
warrant/check be issued to him/her in the sum of $ See attachment .(3)
Signed: 411.4 (4)
Note: Please attach copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
"'"
(5) S t 11:1 0 sworn to before me this ZS day of rr 2011).
Ile
40)i tit
COMMODORE MANN
NOTARY PUBLIC - ARIZONA
My c9mmission expires: MARICOPA COUNTY
Altkif $57( 6/ My Commission May 27, 2019 Expires (seal)
Warrant/Check Number
(if known) (6)
Original Date of Issue
(if known) (7)
Reason for ori ginal issue of Warrant/Check (8):
3 2018
0 Payroll
0 For Services or Goods furnished
0 Treasurer's refund/pa yment
El Other:
KAZEN JEFFREY VIC ID 26461

Summary of Unclaimed Funds
Warrant # Issue Date Vendor Name Warrant Amount
00360006053 9/8/2015 KAZEN JEFFREY $35.00
00360008641 10/8/2015 KAZEN JEFFREY $35.00
00360011174 11/10/2015 KAZEN JEFFREY $35.00
00360013169 12/7/2015 KAZEN JEFFREY $35.00
0036001596 1/5/2016 KAZEN JEF1'REY
00360018149 2/9/2016 KAZEN JEFFREY $35.00
00360019993 3/3/2016 KAZEN JEFFREY $35.00
00360023267 4/11/2016 KAZEN JEFFREY $35.00
00360025443 5/4/2016 KAZEN JEFFREY $35.00
00360028346 6/7/2016 KAZEN JEFFREY $35.00
Total $350.00