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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: March 13, 2018 To: Clerk of the Board From: Maria Meza Department of Finance , Subject: Affidavits — Replacement of Lost Warrants 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 has 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: JESSE C ROBINSON V#MPSPRS W#380012576 $202.61 D180 GAX 18PS00000482 (HR) Inv #PSPRS482 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Et/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. JESSE C ROBINSON V#MPSPRS (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 19Dec2017 -- (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 himifier in the sum of $202.61 • (3) Signed: (4) Note: Pt4e 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 P-) day of MAO-CAA— 20 l( ERIK SORIANO Notary Public- State otArizona My commiTionitexpires: MARICOPA COUNTY tp 12- 2c, My Commission June 12,2021 Expires (seal) Warrant/Check Number 000000380012576 (if known) (6) Original Date of Issue 19-Dec-2017 APPROVED (if known) (7) kik% n A •n4n Reason for original issue of Warrant/Check (8): BK. BOARD OF SUPERVISORS O Payroll MARICOPA COUNTY O For Services or Goods furnished 0 Treasurer's refund/payment X Other: PSPRS INTEREST PAY/Warrant not received by vendor, lost in mail •