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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: November 21, 2017 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: 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 Dade 2 of this form. YESS (1), being first sworn, upon oath deposes and says: Name/Clamant On or about 07-Nov-201 7 (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 $24,000.00 .(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)S bscribed and sworn to before me this c;-- ( day of thk,6 g, 20 /7. p,14i,o)06-6 NOTARY PUBLIC JONNI WEBB Notary Public,State of Arizona Maricopa County kjy_commiAsion expires: My Commission May 09, 2018 Expires 1 RaAtv-1 .9e) (seal) Warrant/Check Number 380009494 (if known) (6) A-P-P-R-13-11-E-13 Original Date of Issue 07-Nov-2017 (if known) (7) DATbr NOV 2)2 2017 Reason for original issue of Warrant/Check (8): tRK. BOARD OF SUPERVISORS MARICOPA COUNTY LI Payroll For Services or Goods furnished El Treasurer's refund/payment Other: 1(\€0(