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AFFIDAVIT/NOTICE OF CLAIM STATE OF ARIZONA "tvii JUL -2 AM 10: 55 • COUNTY OF MARICOPA HUMAN RESOURCES l,/40-61a,cx /47 . - 467 i.z...46) BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the *2- 7 day of ZIE , 20 he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of 414/ ,, said claim being in the sum of F/ VA- 'Ace, Dollars ($ 57 7. 9 ) in payment of which the Board of Supervisors caused the Warrant No. 1Y02 20 90,2to be issued on ,20 /3 , 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. 12022agog,2V In the sum of $ Dated: to102-7 , 20 /X Signed: Affiant Subscribed and sworn to before me t My commission expires: NOTARY JINKY PUBLIC COLLINS - ARIZONA OcytO-D-,-01L1 My MARICOPA Commission COUNTY Expires October 22, 2014 UPON APPROVAL. PLEASE MAIL REPLACEMENT CHECK TO: 7/23/2010