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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: February 6, 2017 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 APPROVED nAT4 112-011____ K. BOARD SUPERVISORS MARICOPA COUNTY Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 1151 Duplicate or 0 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 Dade 2 of this form. SHEILA PILAT (1), being first sworn, upon oath deposes and says: Name/claimant On or about 23-Jan-2017 (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 bffl issued to,kim/her in the sum of $ 923.08 .(3) Signed: V (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) Sulicribed a sworn, to before this 10' day of 20 N T R PU IC I HAYLEY WOLF My'co mission expires: Notary Public- State of Arizona P/2) .- 210R0 MARICOPA COUNTY 4 at My Commission Expires April 12, 202 Warrant/Check Number 370015015 (if known) (6) Original Date of Issue 23-Jan-2017 (if known) (7) Reason for original issue of Warrant/Check (8): O Payroll For Services or Goods furnished O Treasurer's refund/payment LI Other: GARNISHMENT