041118 STALE DATED WARRANTS 3.PDF

MARICOPA COUNTY
Department of Finance
ail I:,
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: December 27, 2017
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
REBECCA FRANKENBERGER
Please find attached 1 Affidavit for a lost warrant to be included on the next available
Board Agenda.
• The attached item has been researched to ensure the warrant in question
has not been cashed or previously re-issued.
• The original warrants have a void/stale date/stop payment done.
Please call me at 506-7291 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: IAP2

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 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
pacie 2 of this form.
Rebecca Frankenberger (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 23 -Sep -2015 (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 $ 40.00 ( 3 )
r/ted
Signed: (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 ore me this Ii day of Decemioer- 20 17 .
NOTARY PU AelftI NP;THANiEl_ bANC.1-1
Plibt - &tate of Arizona
My commission expires: tify PIN COMiTliSSI011 !L COUNTY EXpl1e3
o AligtISt 22, 2020 (seal)
Warrant/Check Number 00360007401
(if known) (6)
Original Date of Issue 23-Sep-2015
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll
O For Services or Goods furnished
O Treasurer's refund/payment
O Other:
DEC 2 7 2017