062718 DUPLICATE WARRANTS 9.PDF

CLEFiX
MARICOPA COUNTY BOARD OF SUPER YISOK'S
MARICoPA COUNTY
Department of Finance
301 West Jefferson, Ste 960 2018 JUN 12 AM 7:146
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: June 8,2018
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
Prescott Valley Municipal Court
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: 11 Duplicate or El Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MARIC,QPA numbers on the Instruction sheet which is
pacie 2 of this form.
PRESCOTT VALLEY MUNICIPAL COURT (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 13-Apr-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 $ 575 . 00 .(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.
(5) Subscribed and sworn to before me this q- day of ‘71..-^e t 20 / .
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NOTARY PUBLIC
Notary Public
My commission expires: Dawn YevePel V Mosher County
//.2,3b-02 My January commission 23, 2021 expires: (seal)
Warrant/Check Number 3010003081
(if known) (6)
Original Date of Issue 13-Apr-2018
(if known) (7)
Reason for original issue of Warrant/Check (8):
Li Payroll
CLERK, BOARD OF SUPERVISORS
111 For Services or Goods furnished MARICOPA COUNTY
LI Treasurer's refund/payment
Other: LOST WARRANT-JAIL BOND INTERFACE
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