091918 DUPLICATE WARRANTS 2.PDF

MARICOPA COUNTY !WARD OF SUPERVISrWS
MARICOPA C011/11 I
Department of Finance
301 West Jefferson, Ste 960 MI AUG 21 AM 10: 59
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: August 21, 2018
To: Clerk of the Board
From: Maria Meza
Department of Finance
Subject: Affidavits — Replacement of Lost Warrants
Please find attached Affidavit for lost warrant to be included on the next available Board
Agenda.
• The attached item/s have 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 506-1336 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: MVICTIM LORENA MONSIVAIS
W#30I0008651 $14,641.60
DI90 GAX1D 18 -44394
Inv #00000056746C
Fund-219 Dept-D190 County Attorney

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 21 Duplicate or 11 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
Daae 2 of this form.
(1), being first sworn, upon oath deposes and says:
Name/Claimant (-) (-1
On or about e 6 -do - 9 <D iv (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 $ k 4-1 , 6 14 60 .(3)
Signed: V_OP 12-11 MO vc, Lcy catire_. (4)
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 03t day of 0 9 u 20 (
41
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My commission expires: My November COMM1SS1011 6,2010 Expires
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Warrant/Check Number
(if known) (6)
Original Date of Issue
(if known) (7) -
Reason for for original issue of Warrant/Check (8):
0 Payroll CLERKEKWpORsupERvmaR6 . _ 'MA-Mr4TN‘CCitiNsTY/
LI For Services or Goods furnished
111 Treasurer's refund/payment
tx Other: C 1/40
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