060717 STALE DATED WARRANTS 1.PDF

MARICOPA COUNTY 30ARD OF caL,/
Department of Finance MA1lC Ii'
301 West Jefferson, Ste 960 2017 MAY 19 j()
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: May 19, 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: Nolan Smith

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate or v 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.
NOLAN S SMITH (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 16-Jul-2015 (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 hinn/ber in the sum of $ 3,668.55 .( 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 day of /4/AZA:it 207'
NOTARY PUBLICNitnessed - .. .. . as to Execution KITTY Notary Public LAM
or Suite Given.. izu8 -1030 WEST GEORGIA ST.
My commission expires: VANCOUVER, B.C. V6E 2Y3
447g-e": 604-687-0755 (seal)
Warrant/Check Number 00828069
(if known) (6)
Original Date of Issue 15-Jul-2015
(if known) (7)_
Reason for original issue of Warrant/Check (8):
0 Payroll
0 For Services or Goods furnished
El Treasurer's refund/payment
Other: Warrant was never received and presumed lost.