110817 STALE DATED WARRANT 1.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: October 17, 2017
To: Clerk of the Board
From: Marcia J. Clark
Department of Finance
Subject: Affidavit — Replacement of Lost Warrant
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: -7 Duplicate or El 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
paae 2 of this form.
Tanya Perez (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 05-Jul-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 im/her in the sum of $ 10,000.00 .(3)
Signed: .,\•.,/r/ 6",„ . ; (4)
-
Note: Pleas-‘ attach a co 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 IA day of &tic b y ; 20_4.
\JCri ict-ia ct Li
NOTARY PUBLIC VERONICA FtAZO
Notary Public- Slate of Arizona
MARICOPA COUNTY
My commission expires: My Commiseon Expires
V)c- I November 0, 2010 (seal)
Warrant/Check Number 370001572
(if known) (6)
Original Date of Issue 05-Jul-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll c7-
LI For Services or Goods furnished CD
LI Treasurer's t refund/paymen/t
Other: k.V% 00V1/40/\