042518 STALE DATED WARRANT 2.PDF

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 numbers on the
COUNTY OF MARICOPA Instruction sheet which is page 2 of this form.
Kimberly Lorenz (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 2/1/2017 (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 $ 86.45 .(3)
Z4 LUrrL- (4)
lease attach a copy of the warrant/check if available and/or any other
t a warrant/check was originally issued,
(5) Subscribed and-sworn to before me this day of 20
NOTARY PUBLIC
My commission expires:
(seal)
Warrant/Check Number 851456
(if known) (6)
Original Date of Issue 2/1/2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
LI For Services or Goods furnished
Ill Treasurer's refund/payment Parcel 96907465; tax yr 2015; slip 201700081
[1] Other:
S:\PROCESSES\Warrants - Duplicate or Stale\02 Forms\Warrants Checks notice of claim - Copy.doc
Revised April 2015 A.R.S. 11-632 & 11-644

ECEIVED
APR 0 3 2018
March 29,2018 MARICOPA COUNTY
CLERK BOARD OF f:UPERVISORS
wc; r
ract-6/
Maricopa County
Board of Supervisors
301 W Jefferson St, 10 th Floor
Phoenix, AZ 85003-3561
Dear Sir or Madam:
I am writing to request that a stale-dated check be reissued to me. The original check was issued on
2/1/2017 to reimburse me for overpayment of my mother-in-law's property taxes. I made the payment
on her behalf because the tax statements had been mailed to an old address and she was not aware
that she owed anything until the sheriff posted a notice on her front door. After I made the payment,
the account was reviewed and adjusted, and there was a credit balance on the account.
Unfortunately, when the reimbursement check was mailed to me it was sent to the old address. On
4/5/2017 it was returned to the Maricopa County Treasurer, and apparently it was mailed to my
mother-in-law's updated address. My mother-in-law passed away on 3/9/2017, so when it arrived at
her new address it was not forwarded to me.
My sister-in-law finally went through the unopened mail and forwarded the check to me in mid-March
of 2018. By this time it was already stale-dated.
Please re-issue the check (see the enclosed photocopy), and mail it to me at:
Thank you very much.

JPMorgan Chase Bank, N.A.
MARICOPACOUNTYTREASURER PHOENIX, AZ 851456
ROYCE T. FLORA, COUNTY TREASURER ACH R/T 122100024 851456
;
SERVICING BANK ACCOUNT 91-2/1221
al/20l7
PAY
86 Dollars and 45 Cents $86.45
CHECK VOID AFTER 365 DAYS
MARICOPA COUNTY TREASURER
ROYCE T. FLORA, COUNTY TREASURER
MEMO AUTHORIZED SIGNATURE
Ilia LI.." 1: I. 22 L000241: 09000 LI-.0
DETACH AND RETAIN THIS STATEMENT
THE ATTACHED CHECK IS IN PAYMENT OF ITEMS DESCRIBED BELOW. IF NOT CORRECT PLEASE NOTIFY US PROMPTLY. NO RECEIPT DESIRED.
DATE DESCRIPTION AMOUNT
Resolution has reduced taxes
PARCEL 96907465 , TAX YEAR 2015
PHASE: 00168, RES NUM: 08682 kr-e/ra
-3(124Y
02/01/2017 851456 SLIP 201700081 CHECK TOTAL: $86.45
HARLAND CLARKE M20845 70004758 MARICOPA COUNTY TREASURER
ROYCE T. FLORA, COUNTY TREASURER 851456
SERVICING BANK ACCOUNT