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AFFIDAVIT/NOTICE OF CLAIM STATE OF ARIZONA COUNTY OF NIARICOPA &Vs BEING FIRST DULY SWORN OATH, DEPOSES AND SAYS: That on the /- day of vi.110.z , 20 I -5, he/she presented to Maricopa County, for payment a claim for services rendered or supplies furnished during the month of 6 b /z011- , said claim being in the sum of co Dollars ($ ) in payment of which the Board of Supervisors caused the Wan-ant No. OZ / 3500Z t to be issued on 6/6716fef , 20 1 -1.... , 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 hereb3, 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. In the sum of $ Dated: , 20 1?") Signed: Affiant ***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 day of ,2070l27 COLULt— WCULADAA;vvo-Riviltz) Notary Public OFFICIAL SEAL My commission expires: EILEEN WILLIAMS-PREAS L NOTARY PUBLIC - State ot Arizona MARICOPA COUNTY My Comm. Expires Nov. 9, 2014 T UPON TunxT APPROVAL, A DAD MT A T DT PLEASE -E. A CV MAIL A if REPLACEMENT DE'DI A /I L'XII" CHECK A."1_11001" 'I1 .) 1' Name: Ed 1&d Telephone Number: Address: 3 It zy 3 vi Ocv-Ifiay Employee ID #: I 0 5 1.J-i rt) Address: g So PI4X 01'31/2013