090716 DUPLICATE WARRANTS 6 - FINANCE.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: August 8, 2016
C.ta
To: Clerk of the Board 3730.
GI
From: Beth Brown CO
Department of Finance "—Cf
Subject: Affidavit — Replacement of Lost Warrant Cf.?
on
1/4sD
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: Jerry Banicki

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or El 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.
JERRY BANICKI (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 08-Jun-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
the sum of $ 13,800.68 .(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 me this‘ day of 20 .
NOTAIMPUBLIC JANE NIELSEN
NOTARY PUBLIC, ARIZONA
MARICOPA COUNTY
My commission expires: My Commission expires
June 01, 2018 (seal)
Warrant/Check Number 360028489
(if known) (6)
Original Date of Issue 08-Jun-2016
(if known) (7)
Reason for original issue of Warrant/Check (8):
O Payroll
RK, BOARD OF SUPERVISORS
O For Services or Goods furnished MARICOPA COUNTY
O Treasurer's refund/payment
Other: June Rent for Mesa Court Building

TREASURER, OF MARiCOPA COUNTY
06/08(16 0936002 E‘i 89
THIRTEEN THOUSAND EIGHT HUNDRED DOLLARS AND 65/2,00-,
1. 1 13,800.65
JERRY BAN 7 CKT
1a37 PROPERTY C/C. ACM LLC
2122 E n.IGHLAND AVE STE i00
117 -85016
QUESTIONS — 602-06-139 oa AP31-AIL.MAR=COVA.1=0V N6
NtC,Otie,..1-3Lf:;
JERRY BANIC?:: 100360025161, 06/05/16 Ex's13,800.68
RENT 06/20L5 UNITt 2192—BI03—CU .16240050005 15,E00.6
P TJ