062718 STALE DATED WARRANTS 2.PDF

MARICOPA COUNTY BOARD OF 'CLERK SUPER YISC,Pt'S ON\
Department of Finance HARICOPA COUN1
301 West Jefferson, Ste 960 2018 JUN I I AM I I : 34
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: June 11, 2018
To: Clerk of the Board
From: Nadine Higuera
Department of Finance
Subject: Affidavits — Replacement of Stale Dated Warrants
Please find attached 1 Affidavits for stale dated warrant to be included on the next
available Board Agenda.
Please call me at 506-1354 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: TIMOTHY CROWLEY
Dept 500/Sheriff
Fund 255

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 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
Pape 2 of this form.
TIMOTHY CROWLEY (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 05-0ct-2016 (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/ch_ e issued to hinytyar in the sum of $275.00 .(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 a E ,yi-Zefz ime this -5 day of j .20
kOtARY PUBLIC
DANIEL HAK1MEH
Notary Public- State of Arizona
My commission expires: MARICOPA COUNTY
My Commission Expires Jan. 15, 2021 (sea l)
Warrant/Check Number 00370006991
(if known) (6)
Original Date of Issue 05-Oct-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
LI For Services or Goods furnished
LI Treasurer's refund/payment
Other: CHECK WENT STALE-CHECK PRESUMED LOST
51)0
top ass-