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MARICOPA COUNTY D OF ; Department of Finance HARICOPA CO' 301 West Jefferson, Ste 960 UN OCT 30 PH 12: 50 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: October 30, 2018 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. Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: V. Duplicate or 0 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. Kristen Anderson (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 05 -Sep -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 presenttd for payment, or it was not presented for payment within one year after the date of Nsuance. 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 him/her in the sum of $ 346.14 .(3) Signed: (4) Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. OFFICIAL SEAL DARLEES SAMUELS My commission expires: .2C_AC-1 NOTARY MARICOPA PUBLIC COUNTY - ARIZONA My Comm. Expires 07/05/ - Warrant/Check Number 3010014288 (if known) (6) Original Date of Issue 05-Sep-2018 APPROVE (if known) (7) Reason for original issue of Warrant/Check (8): O Payroll LI For Services or Goods furnished O Treasurer's refund/payment • Other: Victim Compensation: VC2018000061-1 Go.A-D 19* 61 q4, 0c1 29 2tn BY: