050615 DUPLICATE WARRANTS - 12.PDF

MARICOPA COUNTY
Department of Finance
301 West Jefferson, Ste 960
Phoenix, Arizona 85003
INTEROFFICE MEMORANDUM
Date: April 29, 2015
To: Clerk of the Board
From: Joyce Maurmann
Department of Finance
Subject: Affidavits — Replacement of Lost Warrant
Please find attached 1 Affidavit for a replacement of a warrant to be included on the
next available Board Agenda.
• The attached item was cashed with a false endorsement.
• The original warrant is marked as a forged warrant
Please call me at 506-1343 if you have any questions. Please return the approved
Affidavits to my attention in the Department of Finance, Suite 960.
Thank you.
Re: Mark Eytnatten

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_
Mark Eynatten (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 05Dec2014 -- (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 $ 90 . 00 -(3)
Signed: itlskc—_ (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 day of -TA 20
NOTARY PUBLIC
Reyna Juarez
Notary Public
My commission expires: Final County, Arizona
My Comm. Expires 10-22-18 (seal)
Warrant/Check Number 350014047
(if known) (6)
Original Date of Issue 05-Dec-2014
(if known) (7)
Z, 7 7 Tk. c5) 7 7 riI)
Reason for original issue of Warrant/Check (8):
El Payroll
LI For Services or Goods furnished
El Treasurer's refund/payment
Other: refund from Park and Rec Dept