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NOTICE OF CLAIM STATE OF ARIZONA COUNTY OF MARICOPA Donald P RoeIke, being first sworn, upon oath deposes and says: That on the 1. day of July, they presented to Maricopa County, for payment, a claim for services overpaid property taxes paid during the year of 2012, said claim being in the sum of dollars, ($21725.73) in payment of which the Maricopa County Board Supervisors caused the Warrant Number 771703 to be issued on 07/25/2012, drawn on the County's Expense Fund. Claimant further says that although he/she was informed and believes that the above mentioned warrant was regularly issued, the same has never been negotiated. . WHEREFORE, claimant requests that the Board of Supervisors issue to him/her a duplicate of said Warrant Number 771703 in the sum of $21,725.73. Signed: Subscribed and sworn to before me this day of A-pf ZA) NOTARY PUBLIC KIM KNQ My commission expires: '2, -Z-E) 1 1 Notary MARICOPA PutAic - COUNTY 2toi My Oamffilsalon Expices AtityR1 1, 2017 Ilcs1datalFinance$1AP PAYNFORMS107 Affidavit Form Blank.doc Revised March 2007 ms 4/28/2014 11:39:37 AM AFFIDAVIT/NOTICE OF CLAIM STATE OF ARIZONA COUNTY OF MARICOPA IcaNne ascotix4/ BEING FIRST DULY SWORN - —o c-) OATH, DEPOSES AND SAYS: ;7-7) .• CD co That on the day of , 20 I LI' , he/she. r") to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of , said claim being in the sum of Sever\ IoutryA Irtd 644n —6-4 Dollars ($ —1S 111 ) in payment of which the Board of Supervisors caused the Warrant No. oc2,205t-issci, to be issued on 6 -6 -2D , 20 , 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 perjuiy, affiant hereby affirms that this claim is correct and the amount shown is due and owing. WHEREFORE, affiant requests that the Board of pervisors issue t . 4im/her a duplicate of said Wan ant No. awpri, In the sum of $ Li Dated: Le 5 , 20 t9) Signed: it ***A $12.00 fee for the stop payment and reissuance ofth warrant will be deducted from the replacement check.*** Subscribed and sworn to before me this 11 day of PTY.' , 204' ?-1161Ak.) LUOLUOMO RIA-C-} Notary liub OFFICIAL SEAL My commission expires: EILEEN WILLIAMS-PREAS NOTARY PUBLIC State of Arizona 1191 20i4 My Comm. MARICOPA Expires COUNTY Nov. 9, 2014 PON APPROVAL PLEASE MATL REPT .ACEMENT C