050918 STALE DATED WARRANTS 5.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003 (46
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INTEROFFICE MEMORANDUM
Date: April 16, 2018
To: Clerk of the Board
From: Walter Chang
Department of Finance
Subject: Affidavits — Replacement of Lost Warrants
Please find attached 1 Affidavits for lost warrants to be included on the next available
Board Agenda.
• The attached items have been researched to ensure the warrant in question
have not been cashed or previously re-issued.
• The original warrants have a void/stale date/stop payment done.
Please call me at 506 - 8747 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: HELENE MARIA WILT

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: LI 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.
Helene Maria Wilt (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 14-Sep-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 $ 20.24 . (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
Lw
NOTARY PUBLIC
DENISE K. ESHBACH
Notary Public - State of Arizona
My commission expires: MAR ICOPA COUNTY
ict My Commission June 15, 2019 Expires (seal)
Warrant/Check Number PAR000005070
Of known) (6) 31COC)50u.)
Original Date of Issue 14-Sep-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
EI Payroll
111 For Services or Goods furnished
ID Treasurer's refund/payment
Other: Victim Compensation claim
Ucko GA),1:11) 1 1Y- (Ve45
C 2015 0040015 - 1