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2o,;R c);- . MARICOPA COUNTY ti,-yJc:07: Department of Finance 2011 OCT r 301 West Jefferson, Ste 960 I 0 Phoenix, Arizona 85003 tta4dukuvAisi INTEROFFICE MEMORANDUM Date: October 16, 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: BRIGHT FUTURE STARS Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This appikation is for: 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 page 2 of this form. Bright Future Stars (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 31-May-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/check be issued to him/her in the sum of $14,997.43 .(3) Signed: (4) Note: Please attach ,J copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) %I-Scribed a 'd sworn to before me this oJ day of 20 ) r)( CORiNNE LEE NOTARY PUBLIC NOTARY PUBLIC, ARIZONA MARICOPA COUNTY My Commission Expires m, ,m7s19n(expires: August 30, 2021 _c9 (seal) Warrant/Check Number 370025244 APPROVED (if known) (6) 20 2017 Original Date of Issue 31-May-2017 (if known) (7) K. jOARC.) OF SUPERVISORS Reason for original issue of Warrant/Check (8): MARICOPA COUNTY El Payroll For Services or Goods furnished El Treasurer's refund/payment 111 Other: