032118 STALE DATE WARRANTS 1.PDF

MARICOPA COUNTY A
Department of Finance
301 West Jefferson, Ste 960 2d13 HAR -2 F 12: 2
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: March 2,2018
To: Clerk of the Board
From: Walter Chang
Department of Finance
Subject: Affidavits — Replacement of Lost Warrants
Please find attached 1 Affidavits for lost warrants 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 warrants have a void/stale date/stop payment done.
Please call me at 506-8747 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: VICTOR BARRON

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: E 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
Pale 2 of this form.
VICTOR BARRON (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 05 -Jan -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 •8sued , to him/her in the sum of $320.00 .( 3)
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 before me this 2- day of 20 C- .
NOTARY PUBLIC
My commission expires:
-2—AY (seal)
Warrant/Check Number 370013735
(if known) (6)
Original Date of Issue 05-Jan-2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
El Payroll
El For Services or Goods furnished
El Treasurer's refund/payment
El Other: check is stale

CALIFORNIA JURAT WITH AFFIANT STATEMENT GOVERNMENT CODE § 8202
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g See Attached Document (Notary to cross out lines 1-6 below)
[A See Statement Below (Lines 1-6 to be completed only by document signer[s], not Notary)
Signature of Document Signer No. 1 Signature of Document Signer No. 2 (if any)
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.
State of California Subscribed and sworn to (or affirmed) before me
County of Los Angeles on this day of ""-1/41;-N , 20 106,
by Date D Month Year
(1) I c-ro
(and (2)
Name( 81 of Signer(V
ANNABEL SANCHEZ I proved to me on the basis of satisfactory evidence
Commission # 2087958 to be the person(0 who appeared before me.
Notary Public - California
Los Angeles County eq,
My Comm Expires Nov 12, 201, Signature
,
Signature of Notary Public
Seal
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
-z.- 1 7- c, tS
Title or Type of Document: fter--t P-P-v11 H f'Die-M Document Date:
Number of Pages: 0 Signer(s) Other Than Named Above: 1•)
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