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AFFIDAVIT/NOTICE OF CLAIM
STATE OF ARIZONA 2.14 MAR 24 PM 2: 44
COUNTY OF MARICOPA MAR4...701A ColtiTY
DEPT. CF aft' TiON3
Leticia S. Ramirez BEING FIRST DULY SWORN
OATH, DEPOSES AND SAYS:
That on the 4th day of December , 20 13 , he/she presented
to Maricopa County, for payment a claim for services rendered or supplies furnished during the
month of November , said claim being in the sum of
One Hundred Ten
Dollars ($ 110.00 ) in payment of which the Board of Supervisors caused the
.16-•
Warrant No. 22049571 to be issued on December 19 20 12 , drX.wn otrthe
Payroll Clearing Account fund. tT r,)
Affiant further says that although he/she was informed and believes that the above metitrone0
warrant was regularly issued, the same has never been received, or has been lost. Under pena2tt.6f x-
peijury, affiant hereby affirms that this claim is correct and the amount shown is due and owing.-.70 "
kr a)
WHEREFORE, affiant requests that the Board of Supervisors issue to him/her a duplicate of said
Warrant No. 22049571 In the sum of $ 110.00
Dated: czatiz.Z.--- /920 / 1
Affi
***A $12.00 fee for the stop payment and reissuanee of
replacement check.***
Subscribed and sworn to before meAns I f/ day of lAger.4.. f20 I 41
Xffre£4..111.1PPailboeiyieliUMINI Cau 1
My commission expires: NOTARY JOSE PSEUD MARTINEZ - ARIZONA
Madimpapc-sity f
/D I r) My 0010{M, Lierfin ell-Slyses IC01 1
UPON APPROVAL, PLEASE MAIL REPLACEMENT C mr.vxttortaz-T-dimitirlviok