091918 STALE DATED WARRANTS 1.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: August 29, 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.
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Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: E Duplicate or 151 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.
Lanisha Cook (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 24-Apr-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 $ 41.68 .(3)
(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 ( day of / 7 20/1 .
//076.i,tio Q-14_/e/
NOTARY PUBLIC KIMBERLY A MARI
Notar/ Public — State of Michigan
County of Genesee
My c mission expires: My Commission Expires JKS. 2024
:LT) .06 Acting in the County of (seal)
Warrant/Check Number 370022213
if known) (6)
Original Date of Issue 24-Apr-2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
LI For Services or Goods furnished
'Treasurer's refund/payment
Other: Victim Compensation Check