072016 DUPLICATE WARRANTS 1 - FINANCE - REDACTED.PDF

MARICOPA COUNTY BOARD OF
Department of Finance hARICOPA SUPFYISOR'S COLINiTY
301 West Jefferson, Ste 960
Phoenix, Arizona 85003 2015 JUN - 12: 36
INTEROFFICE MEMORANDUM
Date: June 1, 2016
To: Clerk of the Board
From: Beth Brown
Department of Finance
Subject: Affidavit — Replacement of Altered/Forged Warrant
Please find attached affidavit for Forged warrant to be included on the next available
Board Agenda.
• The attached item has been researched to ensure the warrant in question
has been cashed.
• The original warrant was altered by inserting a false payee name.
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: AMBA SOLUTIONS INC

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
pacie 2 of this form.
AMBA SOLUTIONS INC (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 02-Feb-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 $ 1,478.50 43)
Signed: 17 11.520AA Uri& (4)
Note: `P'ibase attach a copy or 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 ,9,tq\ day of
\\
NOTARY PUeLIC NOTARY PUBLIC
STATE OF ARIZONA
Maricopa County
My com ission expires: BORDY W. BRILLING
My Commission Expires October 08, 2018 (seal)
Warrant/Check Number 360017478
(if known) (6)
Original Date of Issue 02-Feb-2016 APPROVED
(if known) (7) DATE.. JUIN 0 2016
Reason for original issue of Warrant/Check (8): C:ItigriLIAP4PW ,
K. 8 MARICOPA A D S COUNTY
El Payroll
For Services or Goods furnished during months of Jan. through March, 2016
LI Treasurer's refund/payment
El Other: