011718 STALE DATED WARRANTS 4.PDF

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MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: January 2, 2018
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
PAX RESOURCE CONSULTING
Please find attached 1 Affidavit for a 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 warrants have a void/stale date/stop payment done.
Please call me at 506-7291 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: IAP2

DEC 2 7 2017
Application for a Duplicate or Stale-Datgtramiggprifk
Affidavit/Claim Form
This application is for: D 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.
PAX RESOURCE CONSULTING (1), being 'first sworn, upon oath deposes and says:
Name/Claimant
On or about 27-Dec-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/che be issued to him/her in the sum of $2,095.00 .(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) Subscribed and sworn to before me this çIt day of 0-e 20 /7 .
NOTARY PUBLIC OFFICIAL SEAL
DIANNE FERGUSO
Notary Public - State ofArtz
My commission expires: ° MARICOPACOUN
q-7-- Duc2/ tatt.:!--y 44 My Comm. ExpFsettOpt. 7,
Warrant/Check Number 370013168
(if known) (6)
Original Date of Issue 27-Dec-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
0 Payroll
0 For Services or Goods furnished
0 Treasurer's refund/payment
Other: