081716 STALE DATED WARRANTS 1 - FINANCE.PDF

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MARICOPA COUNTY ao ARD OF CLERK SUPER VISOR'S
Department of Finance HA RICOPA COUNT Y
301 West Jefferson, Ste 960 2016 JUL 21 Pt-I 14: I I
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: July 21, 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: Samuel Ortiz-Labra

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: El Duplicate or 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
paae 2 of this form.
SAMUEL ORTIZ-LABRA (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 23-Feb-2015 (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 $ 26.02 .(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 y day of 20
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NOA1111111111
VERONICA RAZO
My commission expires: Notary MARICOPA Public - State COUNTY of/viz=
My November Commission 6,2018 Expires (seal)
Warrant/Check Number 00350021302
(if known) (6)
Original Date of Issue 23-Feb-2015
(if known) (7)
Reason for original issue of Warrant/Check (8):
0 Payroll
0 For Services or Goods furnished
0 Treasurer's refund/payment
Other: VICTIM CLAIM

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