020117 STALE DATED WARRANT 1_REDACTED.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: December 29, 2016
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Notice of Claim
In -
Please find attached Affidavit for stale dated warrant to be included on the next
available Board Agenda.
• The attached item has been researched to ensure that warrant in question
has not been cashed or previously re-issued.
• The original warrant has a void/stale date/stop payment done.
Please call me at 506-1329 if you have any questions. Please return the approved
Affidavit to my attention in the Department of Finance, Suite 960.
Thank you.
Re: KATHLYNN MILLER

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: U Duplicate or v -I'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
rage 2 of this form.
KATHLYNN MILLER (1), being first sworn, upon oath deposes and says:
Name/C1aimant
On or about 18-Nov-2015 (clate)(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
warr e issued to him/her ill the 5um of $ 779 -90 43 )
(4)
Note: Pleasevattach 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 a d. day of PerLiTid- 0- 20 ieD .
vAs /1(1/1 k aw—w -••I•—II 1ikrit,2
NOTARY RJUBL _ gicr, ''II11At YY1111..11/+ P
• -0 IIALff - iiIcatir
My commissiop expires:
I 90 egor 111 ;•IrrIlfr» I,111c 11111( (seal)
Warrant/Check Number 360011874
(if known) (6)
Original Date of Issue 18-Nov-2015
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll
O For Services or Goods furnished
O Treasurer's refund/payment
Other: Workers comp check never cashed, is now stale date.
RECEIVED
DEC 2 7 2016
RISK MANAGEMENT