041217 DUPLICATE WARRANTS 9_REDACTED.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
0.0
INTEROFFICE MEMORANDUM
Date: March 31, 2017 SZ:15 r)
To: Clerk of the Board
From: Marcia J. Clark
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 -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 0 Stale-Dated (definitions are on page 2)
Note: Numbers on this form correspond to
STATE OF ARIZONA numbers on the Instruction sheet which is
COUNT( OF MARICOPA oaae 2 of this form.
RILEY/SMITH CONSTRUCTION LLC (1), being 'first sworn, upon oath deposes and says:
Name/Claimant
09 -Jan-2017 (date)(2) a warrant/check was issued to the
On or about person/entity in the amount as stated below. Such warrant/check was
above named received or was subsequently inadvertently lost or destroyed and there is
either never probability of its being found or presented for payment, or it was not
no presented reasonable 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 i.sved to him/her in the sum of $ 530.00 . (3 )
(4)
Signed:
Not. Please attach a copy of the warrntiche -Ck if available and/or any other
evidence that a warrant/check was originally issued
(5) IA Subs ribed and sworn to before me this day of /11.11,0---. 20 /7 .
- ' 69114114-di .
NOT/11111 Notary Public State of Arizona
Maricopa County
My commission expires: Lori My Commission Coscarelli Expires 11/09/2018 seal)
8- 41 -73
Warrant/Check Number 370013969
(if known) (6)
Original Date of Issue 09-Jan-2017
(if known) (7)
Reason for original issue of Warrant/Check (8):
D1 Payroll
LI For Services or Goods furnished
El Treasurer's refund/payment
PERMIT REFUND El 63443
151 Other:

Ft. I I_ F. I 5 V'1 I 1---I
-
3/29/17
To whom it may concern,
Dustin Riley is a member of Riley/Smith Development, LLC.
Thanks,
Debbie Smith
Riley /Smith Development, LLC
3106 N. 16th a.
Phoenix, AZ 85016
602.509.0330
PO Box 13567 Phoenix: AZ 85002: 602-509-0330

Page 1 of 1
Warrant 3-7-0013969 Details
Wt Number 3-7-0013969 Wt Amount $530.00
Wt Status OUTSTANDING Wt Interest 0
Acct Num 31-768-000 Issue Date 1/9/2017
Paid Date Register Date
Voucher 000 Claim Number
PO Num Fund Number 768
Dept Num 0000 Low Orig 00000
Payee RILEY/SMITH CONSTRUCTION Sub Fund 000
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https://treasurenmaricopa.gov/Agency/FinanceFunctions/vvtlookup.asp 3/31/2017