042518 STALE DATED WARRANT 1.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
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
has not been cashed or previously re-issued.
• The original warrant has a void/stale date/stop payment done.
Please return the approved Affidavit to my attention in the Department of Finance, Suite
960. If you have any questions please contact me at 602-506-1336.
Thank you.
Re: ALICIA MARTINEZ-BALTAZAR V# MVICTIM
W#000000370005049 $24.73 9/14/16
D190 GAX1D 17-9865
Inv#00000049767C

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 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
Page 2 of this form.
Alicia Martinez-Baltazar (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 08-Sep-201 6 (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 $ 24 .73 .(3)
Signed: .4/7.%e-f- (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 c) day of 1-A 20
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NOTARY PUBLIC
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Warrant/Check Number 000000370006049
(if known) (6)
Original Date of Issue 08-Sep-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
Eli Payroll
0 For Services or Goods furnished
0 Treasurer's refund/payment
Other: VICTIM CLAIM
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