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MARICOPA COUNTY 30,t.RD OF SUPEF;%:: A Department of Finance 301 West Jefferson, Ste 960 2018 JI 31 El 7:0! vb Phoenix, Arizona 85003 \Nos\ INTEROFFICE MEMORANDUM Date: January 31, 2018 To: Clerk of the Board From: Maria Meza Department of Finance Subject: Affidavit — Replacement of Lost Warrant 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 has 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: Life Startup Essentials LLC Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or LI 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 Date 2 of this form. Life Startup Essentials LLC (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 21 -Dec-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 $2,702.50 .(3 ) r'Adit Signed: (4) Note: Please ttach 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 2-3 day of .)CkIVAiin 20), . aYelyt NOTARY PUBLIC OFFICIAL SEAL NATHAN R ELLIOTT My commissionexpires: Notaty Public- State of Arizona obr MARICOPA COUNTY itj 7,021 My Comm. Expires Oct. 9,2021 (seal) Warrant/Check Number 000000380013204 (if known) (6) Original Date of Issue 21-Dec-2017 (if known) (7) DAT Reason for original issue of Warrant/Check (8): 41Plir ERK, 8(045411:4" -4 r- U • -1 MARICOPA COUNTY LII Payroll For Services or Goods furnished Invoice# 175 11/9/17 El Treasurer's refund/payment CI Other: