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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 pane 2 of this form. FELICIA JO ANN SIMPSON (1), being first sworn, upon oath deposes and says: Name/Claimant On or about 09-Apr-2014 (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 $193.00 .( 3) /A Signed: W C,' 7 (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 C)c-I-oVit r 20 14 r4, ROBERT JOSEPH f....) NOTARY PUBLIC - ARIZONA My commission expires: 'A,- Maricopa County 031P-o PC9140 My Commission March 20, 2016 Expires (seal) Warrant/Check Number 340024773 (if known) (6) Original Date of Issue 09-Apr-2014 (if known) (7) rw'r Plk Reason for original issue of Warrant/Check (8): CLERK, BOARD OF SUPERVISORS El Payroll MAR1COPA COUNTY LI For Services or Goods furnished 171 Treasurer's refund/payment El Other: refund from West Mesa Justice Court for overpaid fees AFFIDAVIT/NOTICE OF CLAIM RK, BOARD OF SUPERVISORS MAR ICOPA COUNTY STATE OF ARIZONA 14 OCT -1 30 COUNTY OF MARICOPA HUMAN RESOURCES Michelle Renee Lacroix BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the 25th day of September , 2014 he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of February , said claim being M the sum of One Hundred and Eighty Six Dollars ($186.00) ) in payment of which the Board of Supervisors caused the Warrant No. 22166257 to be issued on February 26 , 2014 , drawn on the Payroll Clearing Account fund. Affiant fin-ther 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 affirms 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. 22166257 / Dated: 40,3 ,20 /1 •,1 Signed: Affiant ***A $12.00 fee for the stop payment and reissuance of the warrant will be deducted from the replacement check.*** PHUONG NGUYEN -d Commonwealth Notary Public of MIWAlfdit0A . and sworn to before me this 6 day of QC . My Commission Exp. Dec. 14, 201E: My commission expires: APPRC1ITAT PI FACF MAlI RFPI ACP-VP-NTT ru-prie- Tel. APPROVE) K, BOARD OF SUPERVISORS FIDAVIT/NOTICE OF CLAIM MARCO PA COUNTY 14 OCT -7 Pt-I 1: 49 201 110C1 STATE OF ARIZONA --6 111111: HUMAN RESOURCES COUNTY OF MARICOPA IIARICOPA COW,: DEPT. OF ELECTIO1 KRISTA MONE MARTIN BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the 30th day of September , 20 14 , he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of August , said claim being in the sum of One Hundred Thirty Dollars ($ 130.00 ) in payment of which the Board of Supervisors caused the Warrant No. 22221771 to be issued on September 24 ,20 14 , 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 affirms 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. 22221771 In the sum of $ j 130.00 Dated: 1 0/ 1(2 , 201q_ Signed: ***4S4-27004ee-fet-the-stop-payment-and-re4ssuattee-of repliteement-eheek.*** JOSEPH Pub113. RODENBACK Slabnikkoolubs Med and sworn to before me this (-11'1 day of &CI.) kr-, 20 (i-t, Correnisslon NovAR iCOPA ExPion COUNTY Feb. 23 201$ My commission expires: TTIC1XT A TITST) fAX 7 A r.` AC, T1 AKA TT T) TT A 0-, TIT. XT71I Plr r,r 1,17 IA PP ROVED DATot OCT 420 AFFIDAVIT/NOTICE OF CLAIM ERK, BOARD OF SUPERVISORS MARICOPA COUNTY STATE OF ARIZONA 0rT IO Ail 9:73 201 11 OCT -9 145 COUNTY OF MARICOPA HUMAN RESOURCES. MA .RICOPA COW. DEP'. OF ELECT) Roseland B Barton BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the 6th day of October , 20 14 , he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of August , said claim being in the sum of One Hundred Fifteen Dollars ($ 115.00 ) in payment of which the Board of Supervisors caused the Warrant No. 22221857 to be issued on September 24 , 20 14 , 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 affirms 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. 22221857 115.00 Dated: `C)-etpt-e,4._.) 7, 20 /171 Signed: Affiant eissunneeef-the-warrant-will-be-dedueted-frent-41te rephreement ehceit.*** Subscribed and sworn to before me this 7 14/ day of $(3-,1-- , 20 otary Public ..- a._a— IL-1- _ML- -M, My commission expires: A.-p./-11 (1 4'1,R 01,C ANDRES BUENO Notary Public - Arizona Maricopa County UPON APPROVAL, PLEASE MAII, RF.PLACEMENT CHF,CK TO- 1 My Comm. Expires Apr 24, 2016 AFFIDAVIT/NOTICE OF CLAIM -?..r.r5iK, BOARD OF SLIPERVIbOitti MARCOPA COUNTY nrT 9:23 2014 OCT -9 II: I ' STATE OF ARIZONA COUNTY OF MARICOPA HUMAN RESOUfiCES- MARICOPA COU; DEPT. OF ELECTIL. Lisa Mary Clifton BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the 30th day of September , 20 14 , he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of August , said claim being in the sum of One Hundred Thirty Dollars ($ 130.00 ) in payment of which the Board of Supervisors caused the Warrant No. 22222341 to be issued on September 24 ,20 14 , 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 affirms 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. 22222341 In the sum of $ 130.00 Dated: 01&/1 6/ , 20 4- Signed: .*22111.--$4.2rO. 0-fee-for-the-AO repiazement-eheek Subscribed and sworn to before me this 0 Notary Public My commission expires: CAROLYN BOSTWICK 11 Notary Public -Arizona Maricopa County Expires 08/15/2018 UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO: APPROVED DAT OCT 2014 AFFIDAVIT/NOTICE OF CLAIM RK, BOARD OF SUPERVISORS MARICOPA COUNTv 14 orT n nil 9:23 2014 OCT —9 PM[: STATE OF ARIZONA COUNTY OF MARICOPA HUMAN RESOURCES MARICOr'A COUN. . DEPT. OF ELECTIONS Jason Randall Goetz BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the 30th day of September , 20 14 , he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of August , said claim being in the sum of One Hundred Dollars ($ 100.00 ) in payment of which the Board of Supervisors caused the Warrant No. 22219783 to be issued on September 24 ,20 14 , 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 affirms 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. 22219783 In the sum of $ 100.00 Dated: (.0 a" , 20 /LI Signed: QA Affiant ***A $12.0 t-will-he-dedueted-frent-the replaeernent-eheek-±±± . Subscribed and sworn to before me this Y.- day of 000 bkr, 20 II( Notary Public My commission expires: ANDREW BERMAN 1VovOivi6e' --1-026 /6' Notary Public - Arizona Maricopa County UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO: My Comm. Expires Nov 1, 2016 APPROVED OCTI4 7011 DAT AFFIDAVIT/NOTICE OF CLAIM CLERK, BOARD OF SUPERVISORS MARICOPA COUNTY orT o fill 9:23 STATE OF ARIZONA ZOlii OCT -9 PH L. HUMAN RE.JOURCES COUNTY OF MARICOPA MARICOPA COW, DEPT. OF ELECTIONS Stephanie B Johns BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the 30th day of September , 20 14 , he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of August , said claim being in the sum of One Hundred Fifteen Dollars ($ 115.00 ) in payment of which the Board of Supervisors caused the Warrant No. 22219976 to be issued on September 24 ,20 14 , 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 affirms 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. 22219976 In the sum of $ 115.00 Dated: Oct, , 20 1 44 Signed: Affiant ***A $12.0 replacernent-eheek Subscribed and sworn to before me this (.01-r\ day 4. ,,Pcili?5f0 I ,i,d1P0A1 YE Notary Pub ic Maricopa W nty My commission expires: 5- ,e3 1 /12 iYMy Comm. Expires May 23. 2016 UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO: APPROVE D OCT 1N4 2014 DATE 411111911k , AFFIDAVIT/NOTICE OF CLAIM V13-- :I; MARICOPA • * COUNTY " it. ITT ! fl All 9:23 STATE OF ARIZONA 2010C1 -9 11111I: COUNTY OF MAR ICOPA HUMAN RESOURCES' GUUi MARICOPA DEPT. OF ELEC1I Betty Ann Michalski BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the 30th day of September , 20 14 , he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of August , said claim being in the sum of One Hundred Fifteen Dollars ($ 115.00 ) in payment of which the Board of Supervisors caused the Warrant No. 22222885 to be issued on September 24 , 20 14 , 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 affirms 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. 22222885 In the sum of $ 115.00 Dated: 10) , 20 Signed: Af iant ***24-$4-2700-fee-fer-the-stop-payment-and-reisst adt-will-be-ek•dueted-front-the repliteement-eiteek.*** Subscribed and sworn to before me this day of 61(4,2c1 L-1 Notary Public! My commission expires: ) AftiP.g74 1 s„' Andrei Notary Marghitas Public Maricopa CoUnty, Ariz UPON APPROVAL, PLEASE MAIL REPLACEMENT CI-IECKLL' 1._.X."45-rr- 1, 7 My Comm. Expires 0: . • j APPROVED AFFIDAVIT/NOTICE OF CLAIM FIK. BOARD OF SUPERVISORS mAn1c3'%. COUNTY 14 OCT 0 AN 9:23 STATE OF ARIZONA 201 11 OCT -8 PH 2: HUMAN RESOURCES COUNTY OF MARICOPA MARICOPA COUP, DEPT. OF ELECTI"' Deborah Kay Addleman BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the 6th day of October , 20 14 , he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of August , said claim being in the sum of One Hundred Fifteen Dollars ($ 115.00 ) in payment of which the Board of Supervisors caused the Warrant No. 22221984 to be issued on September 24 ,20 14 , 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 affirms 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. 22221984 In the sum of $ 115.00 Dated: C)(0 4 , 20/ Signed: Affiant Eravnitettt-ant aanee-af-the-warrant-will-be-dedueted-from-the replacement-check.*** Subscribed and sworn to before me this day of retc 20 ji-f FRANCES HANSON 41:9-Aet1v.t.rt-W 4..ltuvetv:0 *Wry Public- State of Arizona Notary Public mmtcoPA WW1, . ON5MVWMililltdb.tiggif. UPON APPROVAL, PLEASE MAIL REPLACEMENT CHECK TO: APPROVED DATR ()CAA 201 AFFIDAVIT/NOTICE OF CLAIM RK, BOARD OF SUPERVISORS mAalcooncmpv -rv STATE OF ARIZONA nri 10 111111: I 2tIti OCI 10 MI 9: 21 COUNTY OF MARICOPA HUNAI: RI:SOURCES COU'i DEPT. OF ELEci. Richard Anthony Lopez BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the 6th day of October , 20 14 , he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of August , said claim being in the sum of One Hundred Fifteen Dollars ($ 115.00 ) in payment of which the Board of Supervisors caused the Warrant No. 22221779 to be issued on September 24 ,20 14 , 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 affirms 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. 22221779 In the sum of $ ,0fr„ Dated: 1:16, f o , 20 / V Signed: A ffi ant ±*-*A-$127949-fee-for-the-step-payment-and-reisstrattee-of-the-wavill-be-deeltretetl-from-the repliteentatt-eheekidok I c\ LA.m..peo, VI' Subscribed and sworn to before me this day of , 20 1\2 Nota ublic 7, My commission expires: —3tXf\L es" 2-01 ARI NANEZ UPON AP ROXAL, PLEASE MAIL REPLACEMENT CHECK TO: WARY MARCOPA PUSLIC COUNTY - ARIZONA Comm Exp.: July 30, 2011