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hand de \ \VveKve A aa MARICOPA COUNTY SOARD OF SUPERVISOR'S Department of Finance MARICOPA COUNTY 301 West Jefferson, Ste 960 oUIS NOV. 30 AY 10: 04 Phoenix, Arizona 85003 INTEROFFICE MEMORANDUM Date: November 30, 2015 To: Clerk of the Board From: Beth Brown Department of Finance Subject: Affidavits — Replacement of Lost Warrants Please find attached affidavits for lost warrants to be included on the next available Board Agenda. e The attached items have been researched to ensure the warrants in question have not been cashed or previously re-issued. e The original warrants have a void/stale date/stop payment done. Please call me at 506-1329 if you have any questions. Please return the approved Affidavits to my attention in the Department of Finance, Suite 960. Thank you. Re: Wayne and Carolyn Hess Application for a Duplicate or Stale-Dated Warrant/ Check Affidavit/Claim Form This application is for: Duplicate or LJ 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. WAYNE AND CAROLYN HESS (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 02-Oct-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 sum of $ 500.00 (3) y, with: C4 Aslan. VY _v-3J signee Acad 2) (4) warrand heck Note. Please attach a copy of the if available and/or any other evidence that a warrant/check was originally issued. A‘ Va and sworn to before me this ZL) day of IV VQ 20 | ) (er NOTARY PUBLIC = : Carolina Ramos Pct = Notary Public My commission expires: Maricopa County, Ari ‘On| 725 \ \ O, / My Comm. sha 8-23-2019 (seal) ‘Warrant/Check Number | 469998063 (if known) (6) Original Date of Issue 02-Oct-2015 (if known) (7) Reason for original issue of Warrant/Check (8): C1 Payroll For Services or Goods furnished C1 Treasurer's refund/payment !emporary Construction Easement Other: Application for a Duplicate or Stale-Dated Warrant/Check eo2, th a \) Affidavit/Claim Form COU A ig <i This application is for: Duplicate or L] 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 page 2 of this form. WAYNE AND CAROLYN HESS (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 92-Oct-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 sum of $ 100.00 (3) nimperee Note. Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. and sworn before me this ae, day of Vovemboer: 20 iz : ees ? NOTARY PUBLIC Carolina Ramos My commissign expires: : Maricopa seestlebnn County, Arizona DISET LO! q My Comm. Expires 8-23-2019 feel) Warrant/Check Number 360008062 (if known) (6) Original Date of Issue 02-Oct-2015 raat Reason for original issue of Warrant/Check (8): O Payroll For Services or Goods furnished 11 Treasurer's refund/payment |emporary Construction Easement Other: