050918 STALE DATED WARRANTS 6.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003 +16,44 eitver
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: ALEJANDRA GARCIA

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate or El 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
pane 2 of this form.
Alejandra Garcia (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 20-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/check,b issued to him/her in the sum of $2,340.34 .(3)
/
Signed: C:21, (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 3 rr—i day of 20 /7 .
VICTORIA MARIE VILLA
JNUI,MNT RLibLIO - ARIZONA
My commission expires: MARICOPA COUNTY
( 027. dbq My Commission Expires (seal)
March 27, 2019
Warrant/Check Number 000000370012641
(if known) (6)
Original Date of Issue 20-Dec-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
0 Payroll
0 For Services or Goods furnished
El Treasurer's refund/payment
LE Other: check was returned and not cashed v I utivvt CA)v-,T
b\c.) C,poup 11 * 23(.0 3 1
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