062718 DUPLICATE WARRANTS 8.PDF

CLERK
MARICOPA COUNTY SOARD OF SUPERVISOR'S
MARICOPA COUWI Y
Department of Finance
301 West Jefferson, Ste 960 2018 JUN 12 All 7: 46
Phoenix, Arizona 85003 6YA
INTEROFFICE MEMORANDUM
Date: June 8, 2018
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
Leo Kahn MD PC
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.

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate or 0 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
Dade 2 of this form.
ti A-4 D PC:- (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about lit" i(-1 6A-1 - 201g (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 $ C)C D° .(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.
bed and sworn to before me this 15/- day of 20 al .
TAMMY K SQUIRE
My commission expires: NOTARY PUBLIC -ARIZONA
317-11 Maricopa County (seal)
Warrant/Check Number
(if known) (6)
Original Date of Issue 1 - May - /
(if known) (7) A
Reason for original issue of Warrant/Check (8):
LI Payroll CLERK, BOARD OF SUPERVISORS
MARICOPA COUNTY
0 For Services or Goods furnished
0 Treasurer's refund/payment
1% Other: eh-e6k_ los or) ry) Li
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