050918 STALE DATED WARRANTS 1.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: April 11,2018
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Replacement of Stale -Dated Warrant
Please find attached affidavit for 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 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.
0/10i,
Thank you.
Re: KAMMAR ENTERPRISES '21110 APR

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is fore 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
Dam 2 of this form,
(1), being first sworn, upon oath deposes and says:
Name/claimant
On or about See attachment (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 attachment -(3)
Signed: (4)
Note: Please attach a copy of the wanant/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: 14 Ockg
seal)
Warrant/Check Number
(if known) (6) 370015883
Original Date of Issue
(if knowq,(7)
Reason for original issue of Warrant/Check (8):
El Payroll
El For Services or Goods furnished
Treasurer's refund/payment
Other:

A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate
is attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of —14-14,4a4y I skirt)
Subscribed and kvorr) to (or affirmed) before me on this 2- /
day of 02/ /W41"-", 20 1 )7, by pAAA?
proved to me on the basis of satisfactory evidence to be the
me.
BRUCE C. TUTTLE
Commission # 2107930
Notary Public - California E
San Luis Obispo County 12
My Comm. Expires Apr 20, 2019
(Seal)

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