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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: November 7, 2018 oP To: Clerk of the Board From: Beth Brown 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 506-1329 if you have any questions. Please return the approved Affidavit to my attention in the Department of Finance, Suite 960. Thank you. Re: Monica Nelson E • .'ansosa T • Application for a Duplicate or Stale-Dated Warrant/Che BY: Affidavit/Claim Form This application is for: GI 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 paae 2 of this form. Monica Nelson (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 14 -Nov-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/check be issued to him/her in the sum of $223.31 . (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 o before me this 'D `-,) day of kinua,m1..-- 201 . Joe Gongora Notary Public My commission expires: Marlcopa County, Arizona My Comm. Expires O 31O19 Warrant/Check Number 000000380010045 (if known) (6) Original Date of Issue 14-Nov-2017 (if known) (7) DAT Reason for original issue of Warrant/Check (8): O Payroll MARICOPA BOARD OF COUNTY SUPERVISORS O For Services or Goods furnished O Treasurer's refund/payment Other: Victim Compensation #VC2014021862-1 ‘56an