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MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960 21110 12: t',9
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: April 5, 2018
To: Clerk of the Board
From: Maria Meza
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
Please find attached Affidavit for lost warrant 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 warrant have a void/stale date/stop payment done.
Please call me at 506-1336 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: MARIA RODRIGUEZ V# MVICTIM
W#380008520 $1906.00 10/23/17
D190 GAX1D-12829
Inv #00000054063C
Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: IN 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
Dacie 2 of this form.
c- '2 (1), being first sworn, upon oath deposes and says:
ri9 cca !WA t
On or about (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 $ t CA cc0 .( 3)
Signed: Atai.//;1' iitaV4-A/K-/ (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 5r, day of (C., CI 20 t
c.clot c EY Z-1.0
NOTARY PUBLIC
VERONICA RAZO
Notary Public - Stated Artzcos
My commission expires: MARICOPA COUNTY
6 My November Commission 6, 2018 Expires (seal)
Warrant/Check Number
(if known) (6)
Original Date of Issue
(if known) (7) /I 7
Reason for original issue of Warrant/Check (8):
'ERK. MARICOPA BOAR 2) C;UUN'
0 Payroll
For Services or Goods furnished
111 Treasurer's refund/payment
t:Ft Other: irr-.{. CQ'c._ \\) a IN) 0,011ty (1 - 't
C,0,01) D\CI c),