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MARICOPA COUNTY OAAO OF 'LUPE' 1-1ARICOrit. Department of Finance 301 West Jefferson, Ste 960 1011 OCT 23 Ph 3: 31. 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 Stale Dated 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 stale dated. 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 716— D190 —COUNTY ATTORNEY tkvte.j s 6. irockt-:,(0-10 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 MARICOPAe4 •-t numbers on the Instruction sheet which is Pacie 2 of this form. bk5 t"-e 9 r- ( 1), 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 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 -(3) (4) tse 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 )--/Th day of Deithill 20 / pite NItiftib OTARY PUBLIC RACHEL A SMITH MY Commission expires: Not Maricopa Public County - Arizona cNadl ;3,9 4/ My Comm. Commission Expires # Aug 549975 21, 2022 (seal) Warrant/Check Number (if known) (6) See attachment Original Date of Issue (if known) (7) Reason for original issue of Warrant/Check (8): 0 Payroll 0 For Services or Goods furnished 0 Treasurer's refund/payment Other: Re.-Pvni) 1i1 "b -A—qp - Cour\ \1 (ine) :S'. r Mt) Victim ID 19483-CANYON PAINT SUPPLY