REDACTED - FOR AGENDA ATTACHMENT - MARY THOMPSON .PDF

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Application for a Duplicate or Stale-Dated Warrant/Check
Affidavit/Claim Form

This application is for: oO Duplicate or Stale-Dated (definitions are on page 2)

STATE OF ARIZONA Note: Numbers on this form correspond to

COUNTY OF MARICOPA numbers on the Instruction sheet which is
paae 2 of this form.

MARY THOMSON (1), being first sworn, upon oath deposes and says:
On or about 24-Aug-2020 (date)(2) a warrant/check was issued to the

above named person/entity in the amount as stated below. Such warrant/check was
either never received or was subsequently inadvertently lost or destroyed and there is
no reasonable probability of its being found or presented for payment, or it was not
presented for payment within one year after the date of issuance.

Therefore, under penalty of perjury, claimant hereby affirms that this claim is correct
and the amount shown is due and owing, and the applicant requests that a replacement

warrant/check be,ésu .(3)

Signed: _~ (4)

/
Note: Please attach a copy of the warrant/check if available and/or any other
evidence that a warrant/check was originally issued.

(5) Subscribed and sworn to before me this_ “7 day of £#BRuney 20_23-

NOTARY PUBLIC \)

NOTARY PUBLIC
STATE OF ARIZONA
E Pinal County
CELESTE A ZWOLINSKI( eal)
My Commission Expires April 30, 2022

My commission expires:
HAIL 30 2oO3d-

Warrant/Check Number
(if known) (6) 3010067340
Original Date of Issue
9 (if known) (7) 24-Aug-2020

Reason for original issue of Warrant/Check (8):

O1 Payroll

For Services or Goods furnished

(2 Treasurer’s refund/payment
Other; ORIGINAL CHECK PRESUMED LOST.

For Questions -

or email

MARICOPA COUNTY DEPARTMENT OF FINANCE

NOT NEGOTIABLE

RETAIN THIS FOR | PAYEE WARRANT NO. | WARRANT DATE | WARRANT AMOUNT
YOUR RECORDS
MISCELLANEOUS BOND RETURN 3010067340 09/24/2020 $3,200.00
INVOICE NUMBER | DESCRIPTION PURCHASE ORDER NO. | VOUCHER NO. AMOUNT
TC201900537 RELEASE OF CASH BOND #TC201900537 GAX1D D440 210000004984 3,200.00
210000004984

THIS DOCUMENT.

TREASURER.O

PAY TO THE ORDER OF
MARY THOMSON

Ry

Three Thousand Two Hundred And 00/100 Dollars

088 Hog

"

ONTAINS A TRUE WATERMARK HOLD TO LIGHT TO VIEW

MARIGO

PHOENIX, ARIZONA\

DATE
09-24-2020

Void After
365 Days

WARRANT.NUMBER
3010067340

91-2/1221

$3,200.00
AMOUNT

CLERK OF THE BOARD

(ED petals on Back:

curity Features included.

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