110817 STALE DATED WARRANT 2.PDF

MARICOPA COUNTY T
Department of Finance • 2011 OCT S H I]: 57
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
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: LUNDMARK BARBERICH LAMONT & SLAV

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: El Duplicate or 1 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.
LUNDMARK ,BARBERICH, LAMONT, & SLAV (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 26 -Apr-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 $ 259.00 .(3)
Signed: , _L, (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) Subscrib, and sworn before me this /7 day of __________ 20
f
NOTARY PI5BLrC
Lynne Crane
My commission expires: Notary Public - Arizona
4 Maricopa County (seal)
My Commission Expires
_February 10 20
Warrant/Check Number 00360024663
(if known) (6)
Original Date of Issue 26-Apr-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
El For Services or Goods furnished
D Treasurer's refund/payment
Other: check lost I never received