090617 STALE DATED WARRANTS 1.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: August 11,2017
To: Clerk of the Board
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From: Walter Chang
Department of Finance
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Subject: Affidavits — Replacement of Lost Warrants
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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: MISSION CHRISTIAN FELLOWSHIP

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: El 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
paae 2 of this form.
MISSION CHRISTIAN FELLOWSHIP ki) t. being first sworn, upon oath deposes and says:
Name/Claimant
On or about 25-May-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 (73 hi her in the sum of $615.00 .(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 C.)1." day of u5A- 201 -7.
NOTARY P LTC LENE POPE
Notary Public - State of Arizona
- My commission expires: My MARICOPA Commission COUNTY Expires
Mpr Li , ?oz. April 4, 2021 (seal)
Warrant/Check Number 360027104
Of known) (6)
Original Date of Issue 25-May-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
0 Payroll
For Services or Goods furnished
0 Treasurer's refund/payment
Other: check presumed lost