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MARICOPA COUNTY Department of Finance 301 West Jefferson, Ste 960 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: December 20, 2016 To: Clerk of the Board From: Beth Brown Department of Finance Subject: Affidavit — Replacement of Lost Warrant Please find attached affidavit for lost warrant to be included on the next available Board Agenda. • The attached item has been researched to ensure the 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: WEST MESA JUSTICE COURT D'N :6 I:"! 1 jz-0 912 S,?: 0 /.11,:1-10j S A. :12 cin S ci0;:)111-7N 4 \ S •"1 0 0 21 V CI C I Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: 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 one 2 of this form. WEST MESA JUJSTICE COURT (I), being first sworn, upon oath deposes and says: Name/Claimant On or about 27-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 h" /her the sum of $ 300.00 .(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. SHIRLEY YOST Notary Public- State of ArizOrte FINAL COUNTY My Commission Expires Mayo, 2((t4X Warrant/Check Number 360027383 (if known) (6) Original Date of Issue 27-May-2016 (if known) (7) P F OVED Reason for original issue of Warrant/Check (8): ID Payroll CPAR*1 )F1s R?1 _ MARICOPA COUNTY El For Services or Goods furnished 11 Treasurer's refund/payment Other: Bail Bond posted tt,r Li rq t- tc,r cr.a ;11 IT; C.) 1.1 ICJ t (ft 1 I It I 1 D I , 1 I 1 C; r-1 rrj IV 0