011718 STALE DATED WARRANTS 1.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
C=7
INTEROFFICE MEMORANDUM
r
Date: December 12, 2017
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
DESERT MISSION
Please find attached 1 Affidavit for a 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 warrants have a void/stale date/stop payment done.
Please call me at 506-7291 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: IAP2

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 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
Pane 2 of this form.
DESERT MISSION (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about I 8-Mar-201 6 (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, gr 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 $6,471.84 .(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) Subs ibed and sworn to before me this '..o of iIlostennber 20 1)
AURORA R. ORTIZ
My commission expires: Notary MARICOPA Public - State COUNTY of Arizona
ttotAmy 2? , 2 i3 My January Commission 28, 2018 Expires (seal)
Warrant/Check Number 360021351
(if known) (6)
Original Date of Issue 18-Mar-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll
For Services or Goods furnished
0 Treasurer's refund/payment
0 Other: