052318 STALE DATED WARRANT 8.PDF

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 numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
Safeway Inc (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 10/26/2016 (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/check be issued to him/her in the sum of $ see attached .(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 day of 20
NOTARY PUBLIC
My commission expires:
(seal)
Warrant/Check Number see attached
(if known) (6)
Original Date of Issue 10/26/2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
111 For Services or Goods furnished
II Treasurer's refund/payment
Li Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S. 11-632 & 11-644

RECEIVED
MAY -7 2018
CPTS
MARICOPA COUNTY
Comprehensive Property Tax Service CLERK BOARD OF SUPERVISORS
1371 Oakland Blvd., Suite 200
Walnut Creek, CA 94596
(925) 938-2244 Fax: (925) 938-2249
May 1,2018
Board of Supervisors
301 W Jefferson St, 10t h Floor
Phoenix, AZ 85003-3561
Subject: Reissue voided refund checks request
Parcel #160-29-090B
Board of Supervisors,
Per my email correspondence with Nancy Jones-Treasz, 5/1/2018 regarding stale refund
checks: 846999, 846975 & 846915 — issued 10/20/2016 — amounts $1,511.70, $775.57 &
$679.85 for parcel #160-29-090B, Safeway is requesting refund checks be reissued due to non-
receive.
We are providing the following documents:
• "Activities" 160-29-090B showing 2013, 2014, 2015 refund amounts.
• Maricopa County Assessor Notice of claim.
• Check info on #846975 & 846915
Please review the documents and remit the refund payment to the following:
Safeway Inc.
1371 Oakland Blvd., #200
Walnut Creek, CA 94596-8408
Please contact me with any question at 925-938-2244, ext. 320 or you may email me at
tiffany.slagle@albertsons.com .
Tiffany Slagle
CPTS, Authorized Agent for
Safeway Inc.