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MARICOPA COUNTY OAR D OF SUPEE
MARICOP A. COMO Y
Department of Finance Qv,
301 West Jefferson, Ste 960 1018 OCT 23 PM 3: 34
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: October 23, 2018
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
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
Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: v 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
page 2 of this form.
Bethany Sollenberger (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 13-Feb-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/ heck be issued to him/herin . the sum of $ 247.50 .(3)
Signed: (4)
Note: Pl9áse attach a \copy of the ,,Warrant/check if available and/or any other
evidercê that a warrant/check was originally issued.
(5) Subscribed and sworn to before me this day of alid-ei,/ 20 (±L.
NOTARY PUB C CHRISTOPHER RICHARD TRACY
NOTARY PUBLIC
My commission expires: STATE OF COLORADO
-te 1(' MY COWMAN NOTARY ID kkiliFit§ 20124013326 A:11,V 1044316
Warrant/Check Number 000000380017108
(if known) (6)
Original Date of Issue 13-Feb-2018
(if known) (7)
Reason for original issue of Warrant/Check (8):
CLERK. BOARD OF SUPERVISORS
III Payroll MARICOPA COUNTY
111 For Services or Goods furnished
El Treasurer's refund/payment
Other: Victim Compensation: VC2016000552-1 (IVA- 28
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