011117 DUPLICATE WARRANTS 8_REDACTED.PDF

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MARICOPA COUNTY BoARD OF SUPE,
R IC ID I-) E:ou:--1
Department of Finance
301 West Jefferson, Ste 966. 1 G DEC"('. I F- 3
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: December 20, 2016
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: PROGRESSIVE ADVANCE INSURANCE

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: IS Duplicate or 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
Dade 2 of this form.
PROGRESSIVE ADVANCE INSURANCE (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 20-Jun-2016 (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
warrant/check beAssued to him/her in the sum of $ 6,331.81 .( 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 TsA, , , day of 20
,-- ,,\N!..1),1:11 AL 4I4,,, KELLIE BLOOD
, Notary Public State of Ohio
NOTARY PUBLIC 7.*
*E" Recorded in Lake County
My commission expires: My commission expires
'Vile 0 September 26, 2021 (seal)
Warrant/Check Number 00360029609
(if known) (6)
Original Date of Issue 20-Jun-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll K, BOARD OF SUPERVISORS
MARICOPA COUNTY
111 For Services or Goods furnished
El Treasurer's refund/payment
Other: Warrant was never received and presumed lost.

v., A rotiai
TREASURER OF MAFilCOPA COUNTY
PHOENIX, ARIZONA
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PAY TO THE ODE IR OF VOIC)ARTER 986 DAYS f4 " 6, 3.31. 81
PROGRESSIVE ADVANCE INSURANCE
A/S/0 JASON WILLIAMS
PO BOX 512929
LOS ANGELES CA 90051
16
QUESTIONS — 602-506-1379 OR A pt:I. . MARI C C PA . GOV
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