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CLERK ±I MARICOPA COUNTY 30A RD OF SUPER Y1SOR'S Department of Finance 1-1ARICOPA C.OUNI y 301 West Jefferson, Ste 960 2015 OCT 27 All (.': I Phoenix, Arizona 85003 --i-: 110 i ti lAuri i INTEROFFICE MEMORANDUM Date: October 27, 2015 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: Tamra Eaton Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: [i1 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 paae 2 of this form. Tamra Eaton (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 22-Sep-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 hi her in the sum of $ 1,040.95 .(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 efore day of Octbit 20 / IAAdit-g0 NOTARY PUBLIC ANNELIESE MOUGHARBEL NOTARY PUBLIC - ARIZONA My commission expires: My Commission Maricope County Expires I 21 December 7, 2016 seal) Warrant/Check Number 00360007441 (if known) (6) Original Date of Issue 123-Sep-2015 (if known) (7) Reason for original issue of Warrant/Check (8): 0012 7 2015 CI Payroll RK, BOARD OF SUPERVISORS MARICOPA COUNTY 0 For Services or Goods furnished CI Treasurer's refund/payment Other: Settlement AL6406419163857 RECEIVED OCT 21 2015 RISK MANAGEMENT f21