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CLERK MARICOPA COUNTY 30A RD OF SUPERVISOR'S MARMOT'', COUNTY Department of Finance 301 West Jefferson, Ste 960 2015 OCT 27 Fri 4: I LI Phoenix, Arizona 85003 i (I/1 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: Taylor and Associates 0/0 Maria Anthoinette Land Application for a Duplicate or Stale-Dated Warrant/Check Affidavit/Claim Form This application is for: Duplicate or 0 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. Taylor and Associates C/O Maria Anthoinette Land ,.. (.1.) being first sworn, upon oath deposes and says: Name/Claimant On or about 05-0ct-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 $ 2,662.24 .(3) t(1114 LiAr Ck AQc Hdrici (AAA Signed: Note: Please attach a copy of the warrant/check if available and/or any other evidence that a warrant/check was originally issued. (5) Subscled and sworh pp before me this z2i- day of COeiw-4,- 20 / . :- NOTARY PUBLIC BONNIE S. DRESCHER My commission expires: Notary MARICOPA Public - State COUNTY of Arizona My Commission Expires (seal) April 2, 2017 Warrant/Check Number 360008322 (if known) (6) Original Date of Issue 05-Oct-2015 (if known) (7) Reason for original issue of Warrant/Check (8): DAT,E 011\ 2 7 2015 0 Payroll 0 For Services or Goods furnished Li Treasurer's refund/payment Other: Workers' Compensation 8/17/2015 - 9/13/2015 RECEIVED OCT 26 2015 RISK MANAGEMENT T_TEZIaR C ASS ,aCIATES 0[3 MkRIA 14,NTHTNETTE L.T=LND az: E AVE, ETE. z. - '32 2,662.24 -