052318 STALE DATED WARRANT 6.PDF

RECEIVED
MARICOPA COUNTY
MAY -73 2013
Department of Finance
301 West Jefferson, Ste 960 MARICOPA COUNTY
CLERK BOARD OF SUPERVISORS
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: May 8, 2018
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Notice of Claim
Please find attached Affidavit for stale dated warrant to be included on the next
available Board Agenda.
• The attached item has been researched to ensure that 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 506-1329 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: Rafael Ortega

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 11 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
paae 2 of this form.
Rafael Ortega (1), being first sworn, upon oath deposes and says:
Name/claimant
On or about 05-Dec-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/cher4 be issued to him/her in the sum of $41.40 .(3)
Signed: [(LI' CZ4777 (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 t day of Nc4 y 20 /
VQ co fe V-c-A -cc
NOTARY PUBLIC VERONICA FtAZO
NO(aiy Public- State of Altana
My commission expires: My MARICOPA Commission COUNTY Expires
i'Vi P ,2d) 1 (6' ..11.701.11.1.11611 November 6, 2018 seal)
Warrant/Check Number 370012400
(if known) (6)
Original Date of Issue
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll
O For Services or Goods furnished
O Treasurer's refund/payment
Other: (UrCIVOSCut \Ca. at 01.-' ‘r\Q-W-C \\C1-1--"Q-6
V 0- 2Gi (davit 9 - I rT&A GAYA-b 4c 2 56 o \ cit)