120716 DUPLICATE WARRANTS 10_REDACTED.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: November 22, 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: Josephine Celestino

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or U 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
bade 2 of this form.
Josephine Celestino (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 19-Sep-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 him/her in the sum of $ 187.00 .(3)
Signed: CISb-LLO (4)
Notd: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.
(5) SubscribecOnd § rn to before me this of e7/1-- 20 /4
NOTARY PUBLIC
BETTY J BURG
NOTARY PUBLIC, ARIZONA
My commission expires: MARICOPA COUNTY
My Commission Expires (seal)
February 04, 2019
Warrant/Check Number 370005489
(if known) (6)
Original Date of Issue 1 9-Sep-20 1 6
(if known) (7) ArlioiLa_u_v4 -
NO 9 2016
Reason for original issue of Warrant/Check (8): DAT-
El Payroll K BOARD OF SUPERVISORS
0 For Services or Goods furnished MARICOPA COUNTY
0 Treasurer's refund/payment
Other: Ironwood Justice Court refund for overpaid fees