011718 STALE DATED WARRANTS 2.PDF

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MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960 c
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: December 15, 2017
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: JOSE J RODRIGUEZ MORALES

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate or /I 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
bade 2 of this form.
Jose J Rodriguez Morales (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 16 -Aug -2016 (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 $ 4 . 57 .(3)
Signed: ô (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) Sijizscribed and sr to before me this day of Nce.11A6e-4-20
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NOT IC
CRYSTAL GALAZ
Notary Public - Arizona
My commission expires: Maricopa County
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Warrant/Check Number 000000370002918
(if known) (6)
Original Date of Issue 16-Aug-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
0 Payroll
0 For Services or Goods furnished
LI Treasurer's refund/payment
Other: VICTIM CLAIM