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APPROVID AFFIDAVIT/NOTICE OF CLAIM DATE. 14 it, BOARD OF SUPERVISORB STATE OF ARIZONA MARICOPA COUNTY COUNTY OF MARICOPA Roderic Pittman BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the q day of , 20 1 Li, he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of , said claim being in the sum of Dollars ($_589.57 ) in payment of which the Board of Supervisors caused the Warrant No. 22205601 to be issued on 7-30 , 2015 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. 22205601 In the sum of $_589.57 Dated: ?"--- , 20 It/ Signed: Affi ant ***A $12.00 fee for the stop payment and reissuance of the warrant will be deducted from the replacement check.*** Subscribed and sworn to before me this 14 day of , 20 \ :03 alkfAiPA/3 Notary Public My commission expires: OFFICIAL SEAL EILEEN WILLIAMS-PREAS cit 20pi i NOTARY PUBLIC - State of Arizona MARICOPA COUNTY ..PP1111 II11111H(1./..11. =3"__„/ISSFF....MMAAIL., Illr__„/[IIIIEEIIIIII --II<I T My Comm, Explros Nov. 9, 2014