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fr: _ MARICOPA COUNTY E-30ARD OF HARICOP,!, Department of Finance 301 West Jefferson, Ste 960 2018 FEB -5 r 9: I 5 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: February 5, 2018 To: Clerk of the Board From: Kathy Baskom 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 item has 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 506-0572 if you have any questions. Please return the approved Affidavit to my attention in the Department of Finance, Suite 960. Thank you. Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or D 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. AMERICAN TIRE DISTRIBUTORS (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 07 -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/cha013„e4 ,396kd Whim/ifier in the sum of $ 100.00 .(3) Signed: (4) Note: Please attach a copy (of the wa ht/check if available and/or any other evidence that a warrant/check was originallY Lssued. (5) Subscribed and sworn to before me this .A th day of ..:(7umccLey 20 icci. . 141/1/ NO ARY PUBLIC NANCY J. BUCKMAN Notary Pubs, Ncrth Camila* My commission expires: Urn n CAntrity ....k,_2& 7171 ' "0"/ 1 1. _ . 1°2 - tr:=. (seal) Warrant/Check Number 380011422 (if known) (6) Original Date of Issue 07-Dec-2017 (if known) (7) ilso Reason for original issue of Warrant/Check (8): FE i o 5 2018 DATfr 1. 0 Payroll El For Services or Goods furnished ERK, BOARD OF SUPERVISORS El Treasurer's refund/payment m Other: Check Lost