012115 MAIN STALE DATED WARRANTS DOCUMENT.PDF

AFFIDAVIT/NOTICE OF CLAIM
STATE OF ARIZONA 14 DEC 12
pH: 42
COUNTY OF MARICOPA HUNAN
'uuRCEs
(;) BEING FIRST DULY SWORN
OATH, DEPOSES AND SAYS:
That on the 25th day of November , 2014 ahe presented
to Maricopa County, for payment a claim for services rendered or supplies furnished during the
month of August 2013 ,said claim being in the sum of
One Hundred Eighty Nine and 00/100
Dollars ($189.00 ) hi payment of which the Board of Supervisors caused the
Warrant No. 22120292 to be issued on 8/28/2013 drawn on the
Payroll Clearing Account fund.
Affiant further says that although he/she was informed and believes that the above mentioned
warrant was regularly issued, the same has never been received, or has been lost. Under penalty of
perjury, affiant hereby WiflIMS that this claim is correct and the amount shown. is due and owing.
WHEREFORE, affiant requests that the Board of Supervisors issue to him/her a duplicate of said
Warrant No. 22120292' In the sum of $189.00
Dated: /....0// , 20 / ‘.(
Affiant
b:04-fe E3-B-Bit-Villeitt-EHEH3
r-eplaeetneat-eheetLiubt
Subscribed and sworn to before me this day of , 20
NiL4-;* cp‘
Notary Public Public
My commission expires:
UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO:

Jurat
State of California
County of 9)0 l(2%)(Aa Pub
Subscribed and sworn to (or affirmed) before me on this qk day of 0,uv)/1 12,A
20 by aA S Helemiez_
proved to me on the basis of satisfactory evidence to be the person) who appeared before me.
Igerv tgnature (Notary seal)
1SUSANA GONZALEZ
Commission # 1960787 [
z Notary Public - California z );
z San Bernardino County -.
Le.v.v.v.gyeCoMM. 24
f(ficnimelAJ.- 4 2eots em)39ssim
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Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: 0 Duplicate or 0 Stale-Dated (definitions are on page 2)
STATE OF ARIZONA Note: Numbers on this form correspond to
COUNTY OF MAR ICOPA numbers on the Instruction sheet which is
7777 7 77777 `711-771_
v7K- e et 14. I *)-- i-C-(1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about IL// / (date)(2) a warrant/check was issued to the
above named persdn/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 $ 3 ./3/i z- .(3)
Sign(d: (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 Z - day of " 4 ki uctrci 20 .
NOTARY PUBLIC
SALLY& PEARSON
kitty Public- State otArizone
My commission expires: MY Commission MAMMA Expires COUNTY Nov. 24, 2017
it/ z ,/117 - 1 (seal)
Warrant/Check Number 1,±1IM
(if known) (6)
Original Date of Issue
(if known) (7) 0/1'1/Y13
Reason for original issue of Warrant/Check (8):
O Payroll
O For Services or Goods furnished
)A, Treasurer's refurd/payment
C:\Users\salpearson\Appdata \Local \Microsoft\Windows \Temporary Internet Files\Content.Outlook\M8JN2Q/Warrants Checks
Notice of Claim.doc
Revised and updated: April 2014 A.R.S. 11-632 & 11-644

Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form
This application is for: Duplicate or II 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
Dace 2 of this form.
West Mesa Justice Court (1), being first sworn, upon oath deposes and says:
Name/Claimant
On or about 15 -Nov-2013 (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 a him/her in the sum of $ 500.00 .(3 )
Signed; (4)
Note: Please attach\v, copy of the warrant/check If available and/or any other
eviden4-e that a warrant/check was originally issued.
(5) Subscyjbed and sworn t before me this day of -54(4. 20L_ 5
WeL
;NOTARY PUBLIC
IRMA LOPEZ ---
My commission expires: Notary MARICOPA Public- State COUNTY of Aitaati
(-1( )-0 My COMmlasion Expires (seal)
August 4, 2017
Warrant/Check Number 340011779
(If known) (6)
Original Date of Issue 15-Nov-2013
(if known) (7)
Reason for original issue of Warrant/Check (8):
LI Payroll
Li For Services or Goods furnished
LI Treasurer's refund/payment
a Other: Jail bond payment