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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: Jul03 , 2018 ;flab 1=0 To: Clerk of the Board h.) From: Marcia J. Clark CA) Department of Finance xa. 9? Subject: Affidavit — Replacement of Lost Warrant CA) <C 0:) cr.; JUNAYED MAHMUD Please find attached 1 Affidavit for a 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 warrants have a void/stale date/stop payment done. Please call me at 506-7291 if you have any questions. Please return the approved Affidavit to my attention in the Department of Finance, Suite 960. Thank you. FUND 750 - RISK MANAGEMENT Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 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 bacie 2 of this form. JUNAYED MAHMUD (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 07-May-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/check be issued to him/her in the sum of $ 6,863.03 .(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. Subscribed and sworn to b e me this 151 of Aol 204_. Seidy Judith Gardea Notary Public My commission expires: Maricopa County, Arizon 01 - b))'0")' My Comm. Expireal -03-2 22 Warrant/Check Number 3010004944 (if known) (6) Original Date of Issue 07-May-2018 (if known) (7) Reason for original issue of Warrant/Check (8): LI Payroll ...— CLERK, BOARD OF S b 0 For Services or Goods furnished MARICOPA COUNTY 0 Treasurer's refund/payment Other: Check lost in mail 1)75d P9/1/21e/ne6--