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MARICOPA COUNTY Department of Finance lealteasiittol 301 West Jefferson, Ste 960 iuu Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: January 11, 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: ENCANTO JP Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Z 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 vane 2 of this form. 7"11/At"1177-1Ju A (1), being first sworn, upon oath deposes and says: Name/clam-tent On or about 12-0ct-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/checki,be issued to him/her i e sum of $ 500.00 - (3 ) (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 day of dr7,71( a,- ty 20 a . azt NOTARY PUBLIC KIMBERLY HASSEL My commission expires: Notary Public - State of Arizona A_ lev Fc, / My Commission MARICOPA Expires COUNTY Nov. 3, 2011 (seal) Warrant/Check Number 380007667 (if known) (6) Original Date of Issue 12-Oct-2017 (If known) (7) intiki 9 2n1it Reason for original issue of Warrant/Check (8): WPM AK. BOARD OF 5UP-ERVI6 1:1 Payroll MARICOPA COUNTY O For Services or Goods furnished O Treasurer's refund/payment O Other: check presumed lost