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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 GD-1 INTEROFFICE MEMORANDUM Date: March 5, 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 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: GILA RIVER INDIAN COMMUNITY GC-0004 W#380008879 $300 D640 IN18-18240 Inv #2017.52X0.01 Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: II Duplicate or 0 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. GILA RIVER INDIAN COMMUNITY (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 30-0ct-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/check4)e issued to.Wei/her in th6L-- 0 .( 3 ) Signed :z- (4) Note: Please iattle:ch a copy of the warrant/check if available and/or any other evidence thatlqiarrant/check was originally issued. (5) Subscribed an sworn to before me this 31(31 day of cutuktI I 20 . IA a NOTARY PUBLIC MA-IRTVIAJ:ARAttnr, Notary Public - Arizon My commi4on expires: • My Commission PINAL COUNTY Exp APRIL 19, 2048 (seal) ti I / Warrant/Check Number 000000380008879 (if known) (6) Original Date of Issue 1 .?0J.DAct.-2.117 mN n 7 71118 (if known) (7) DAT, Reason for original issue of Warrant/Check (8): ERK, BOARD OF SUPERVISORS MARICOPA COUNTY O Payroll For Services or Goods furnished Inv #2017.52X0.01 O Treasurer's refund/payment O Other: